Detoxification services authorizations

Coverage varies by member plan.

Applies to:

Group HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO plans

Medicare Advantage plans

Medical policy

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 substance use disorder detox the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:

Detoxification authorization

Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for urgent/emergent admission to a substance use disorder facility.

We also require ongoing clinical reviews to ensure that the member continues to meet medical necessity criteria for treatment.

In network providers

Submit authorizations through GuidingCare.

Request an authorization

Out of network providers

Out of network providers request mental health and substance use disorder services using our authorization request forms.

Information needed

  • Legal involvement related to substance use
  • Age of first use
  • Age that substance use became problematic
  • Type of substances used
  • Frequency and amount
  • Current vital signs
  • Risk factors
  • Recommendation

Behavioral health fax process

Send a separate fax for each individual patient. Faxes referencing more than one patient will be returned for resubmission.

1.Complete the form for the service you're requesting and use it as the cover sheet for your fax.

2. Identify the evaluating facility/agency contact's name and phone number on the auth form/cover sheet.

3. Attach complete clinical notes or the screening form to ensure that we have all available clinical data to review.

Requirements for clinical notes

Computer-generated or typewritten notes are preferred. Hand-written documentation may delay the review process and require extra phone calls to clarify information and clinical content.

Include:

  • CIWA or COWS score if available
  • All vitals including blood pressure, pulse, temperature and respirations
  • Any specific withdrawal symptoms that the patient is currently exhibiting
  • The specific dates of any transfers from one level of service to another