Partial hospitalization and intensive outpatient services for mental health disorders
Coverage varies by member plan.
Applies to:
Group HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO plans
Medicare Advantage plans don't cover day programs but may cover components of a day program
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, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:
- Medical Necessity - 91447
Authorization
Prior authorization isn't required for substance use intensive outpatient programming.
Members must meet InterQual® Behavioral Health medical necessity criteria for partial hospitalization.
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.
- Autism services
- Community care management
- 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
- Telemedicine
- Transcranial magnetic stimulation