Mental health inpatient authorizations
Coverage varies depending on plan.
Group HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO plans
Medicare Advantage plans
When a member is admitted to a mental health facility as an inpatient for behavioral health treatment.
The term "medical necessity" is used to mean care that is determined to be effective, appropriate and necessary to treat a given patient's disorder. To determine medical necessity for mental health inpatient treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:
Medical Necessity - 91447
Eating Disorders - 91007
Authorization is required
Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for urgent/emergent admission to mental health facilities. When a member is admitted as an inpatient, request authorization using this form:
We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.
Information needed to authorize services:
- Psychosocial information
- Pertinent treatment history
- Risk factors
To request authorizations
For inpatient, residential and partial hospitalization treatment authorization, concurrent reviews, discharges, etc.:
Call during business hours (8 a.m. - 5 p.m.): Behavioral Health Department, 800.673.8043.
After hours, fax a form to 616.975.0249:
- Behavioral Health Inpatient Authorization Request form
- Inpatient Residential Mental Health request form
For intensive outpatient substance use disorder services:
- Fax the Behavioral Health Outpatient Service Request form to 616.975.024.
- Requests for a stepdown from a higher level of care will be discussed at the concurrent review.