Detoxification services authorizations
Coverage varies by member plan.
Group HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO plans
Medicare Advantage plans
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:
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.
Out of network providers
Out of network providers request mental health and substance use disorder services using our authorization request forms.
- 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
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.
- 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
- ADHD services
- Autism services
- Coordination of care
- Depression diagnosis and management
- 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