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 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 Behavioral Health authorization form.
The following information is needed:
- Substance use info including substances being abuse, first use, last use, amount/frequency of use, pattern of use, periods of sobriety, etc.
- Medical complications related to use
- Current withdrawal symptoms
- Vital signs at admission
- Risk factors
- Treatment history
- Mental health history
- Psychosocial Assessment
- Level of motivation and stage of change
- Clinical Recommendation
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