Mental health residential treatment authorizations

Coverage varies depending on plan

Applies to:

Group HMO, EPO, POS and PPO 

Individual MyPriority HMO, POS and PPO

Medical 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:

Medical Necessity - 91447

Behavior Health Residential Treatment - 91625

Eating Disorders - 91007

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.