Partial hospitalization authorizations for mental health services
Coverage varies by member plan.
Applies to:
Group HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO plans
Medicare Advantage plans
Partial hospitalization medical necessity policy
Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for urgent/emergent admission to mental health facilities. We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.
Medical Necessity - 91447
Criteria required for initial and concurrent medical necessity reviews includes but not limited to:
- Chronic medical conditions
- Stressors/symptoms
- Psychosocial information
- Psychotropic medications
- Pertinent treatment history
- Risk factors
- Discharge planning details
- Current symptoms and level of functioning
- Treatment Recommendations
Partial hospitalization authorizations
Authorization is required. Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for partial hospitalization.
You must request authorization prior to sending a member to these programs.
In-network providers
In-network providers can request authorization for mental health and substance use disorder services, evaluations and discharges using GuidingCare.
Out-of-network providers
If you’re a provider located within the state of Michigan and would like to join our provider network, visit our credentialing application page.
Out-of-network providers request mental health and substance use disorder services using our Behavioral Health Authorization Form.
- Autism services
- Community care management
- Clinical guidelines
- Coordination of care
- Discharge process
- Electroconvulsive therapy
- Medicaid behavioral health
- Mental health services
- Neuropsych/psychological exams, testing
- Psychological E&M of non-mental-health disorders
- Substance use disorder services
- Telemedicine
- Transcranial magnetic stimulation