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.

Applies to:

Group HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO 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 partial hospitalization and intensive outpatient treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:

Authorization

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.

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.