General authorization criteria for behavioral health services
Authorizations are patient-specific
Decisions we make using InterQual® Behavioral Health criteria are based on each individual patient's needs. The most appropriate level of care for patients should be the safest and least restrictive possible. The goal of treatment is to restore the patient to an optimal level of functioning and independence.
We realize that no set of criteria can address all the issues; criteria cannot apply to every patient in every situation. Use of the criteria never replaces clinical judgment. We take into consideration:
- Individual patients' needs, which vary in the level of clinical complication
- Service requirements
- Discharge/transfer readiness
- The clinical services available in each patient's geographical area
- For complex cases and/or limited service availability, we may recommend a higher level of care than medically necessary in order to ensure safe, effective treatment.
Consistency and fairness
Priority Health makes every effort to make utilization decisions that are fair and consistent in order to serve the best interests of the member. That is why we:
- Make utilization decisions based only on appropriateness of care and service, as well as existence of coverage
- Will not compensate practitioners or other individuals conducting utilization review for denial of coverage or service
- Will not offer financial incentives for utilization decision-makers to encourage denial of coverage or service
- Decide on coverage of new technology after comprehensive research and careful review by our medical directors and physician committees