Residential/rehabilitation substance use disorder treatment authorization
Coverage varies by member plan
Group HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO plans
Medicare Advantage plans
[What is "residential/rehabilitation" treatment?
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
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.
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.
- ADHD services
- Autism services
- Coordination of care
- Depression diagnosis and management
- 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