Mental health residential treatment authorizations
Coverage varies depending on plan
Group HMO, EPO, POS and PPO
Individual MyPriority HMO, POS and PPO
Priority Health does not contract with any Mental Health or Eating Disorder Residential facilities. To ensure members have access to this level of Behavioral Health care covered within their benefit package, our members have access to Cigna’s national network for this specific level of care. We may approve in-state commercial members (HMO/EPO) for Mental Health Residential Treatment with a Cigna contracted facility.
Please contact our Behavioral Health Department at 800.673.8043 for purposes of care coordination and access to this level of care.
Mental health residential treatment policies
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 residential treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:
Mental health residential authorizations
Authorization is required. In addition to the member meeting medical necessity criteria, the residential program must meet our Residential Facility criteria. We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.
In-network providers can request authorization for mental health and substance use disorder services, evaluations and discharges using GuidingCare.
Out of network providers
Out of network providers request mental health and substance use disorder services using our Behavioral Health authorization form.
Information needed to authorize services:
- Psychosocial information
- Pertinent treatment history
- Risk factors
We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.
- Autism services
- 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
- Transcranial magnetic stimulation