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:
Medical Necessity - 91447
Detoxification - 91104
Auth is required
To admit a member as an inpatient for substance use disorder detoxification treatment, use the Behavioral Health Inpatient Authorization Request form.
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.
- 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.
- Complete the form for the service you're requesting and use it as the cover sheet for your fax.
Inpatient Prior Authorization Form or Outpatient Service Request Form
- Identify the evaluating facility/agency contact's name and phone number on the auth form/cover sheet.
- 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
Response turnaround times
We don't typically process requests during the lunch hour, but a requesting facility will receive a response fax within 1 business day.
- Fax us before 11:00 a.m. - Same-day response
- Fax us after 2:00 p.m. - Response by 11:00 a.m. next business day
- Fax us after 4:00 p.m. - Response by 2:00 p.m. next business day
To request authorizations
For inpatient, residential and partial hospitalization treatment authorization, concurrent reviews, discharges, etc.:
Call during business hours (8 a.m. - 5 p.m.): Behavioral Health Department, 800.673.8043.
After hours, fax a form to 616.975.0249:
- Behavioral Health Inpatient Authorization Request form
- Inpatient Residential Mental Health request form
For intensive outpatient substance use disorder services:
- Fax the Behavioral Health Outpatient Service Request form to 616.975.024.
- Requests for a stepdown from a higher level of care will be discussed at the concurrent review.
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- Discharge process
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- Transcranial magnetic stimulation