Partial hospitalization and intensive outpatient services for substance use disorders
Coverage varies by member plan. Medicare Advantage plans don't cover day programs, but may cover components of a day program.
Group HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO 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 partial hospitalization and intensive outpatient treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:
Medical Necessity - 91447
Authorization is required
Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for partial hospitalization and intensive outpatient programs.
You must request authorization prior to sending a member to these programs.
We also require ongoing clinical reviews to ensure that the member continues to meet medical necessity criteria for treatment.
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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- Coordination of care
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- 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