Residential/rehabilitation substance use disorder treatment authorization

Coverage varies by member plan

Applies to:

Group HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO plans

Medicare Advantage plans


[What is "residential/rehabilitation" treatment?

Medical policies

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 mental health residential treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria [WHERE CAN PROVIDERS FIND THESE?] and Priority Health medical policies:

Medical Necessity - 91447

Mental Health Residential Treatment, Adult - 91608

Mental Health Residential Treatment, Child and Adolescent - 91607

Authorization is required

In addition to the member meeting medical necessity criteria, the residential program must meet our Residential Facility criteria.  [WHERE CAN PROVIDERS FIND THESE?]

We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.