Medicaid behavioral health services
All Priority Health Choice, Inc., members: Medicaid, MIChild, Healthy Michigan Plan
Mild to moderate conditions
Priority Health provides outpatient behavioral health therapy services for Medicaid members with mild to moderate mental health needs. This includes members experiencing or demonstrating mild to moderate psychiatric symptoms or signs of sufficient intensity to cause subjective distress or mildly disordered behavior, with minor or temporary functional limitations or impairments (self-care/daily living skills, social/interpersonal relations, educational/vocational role performance, etc.) and minimal clinical (self/other harm risk) instability.
Requests for first 30 visits
Either members or primary care physicians may contact Priority Health to request services. Use the Behavioral Health Outpatient Services Request form.
Our Behavioral Health team reviews cases of mild to moderate symptoms for clinical appropriateness for services. They authorize the initial 30 visits.
Calendar year expiration date: Since treatment for mild to moderate conditions is generally short-term in nature, those 30 visits could span over any length of time. To make sure claims process correctly, Priority Health uses the end of the calendar year as the expiration date for the first 30 visits.
Treatment beyond 30 visits
We follow a clinical review process when additional outpatient services are requested beyond the initial 30 visits. The purpose of this process is to review the clinical needs of the member and determine if specialty mental health services from CMH would be more appropriate.
When the member has completed at least 26 sessions and meets medical necessity criteria for outpatient therapy services, providers request additional sessions by using the Behavioral Health Outpatient Continuing Treatment Request form. Include the following clinical information:
- Initial assessment
- Treatment plan
- Summary of progress
Behavioral Health clinical staff will follow up with providers if additional information is needed or will assist with coordinating on-going treatment with the local CMH provider as necessary.
Severe conditions, substance use disorders, specialized behavioral health services
Medicaid members with severe mental illness (adults), severe emotional disturbance (children), substance use disorders or developmental disabilities, as defined in the Michigan Mental Health Code, should be directed to their local pre-paid inpatient health plan (PIHP) for evaluation and treatment.
Providers are responsible for referring members to their PIHP if they require specialized behavioral health services.
Members who are being served through the PIHP system of care are generally not eligible to receive mental health outpatient services through Priority Health.
Find the correct PIHP
Bill the PIHP in the member's county of residence. The list of all PIHPs and regions can be found here:
The specific code set to be billed to the proper PIHP can be found by logging into CHAMPS:
- Go to the External Links menu located on the 'Provider Portal' page.
- Select 'Medicaid Code and Rate Reference' from the dropdown list.
Below are links to information on substance use disorders and on acute detoxification:
- Medicaid Provider Manual Go to the "Behavioral Health and Intellectual & Developmental Disability Support and Services" section, then Section 1.6, Beneficiary Eligibility
- MDCH Medicaid Mental Health Substance Use Disorder: Inpatient Medical Acute Detoxification
- MSA Bulletin 17-27 Outpatient Behavioral Health Visits
- MSA Bulletin 16-46 Coverage of Trauma Services for Children Under 21 Years
Medicaid eligibility questions
Questions about Medicaid/Healthy Michigan Plan members' service eligibility should be directed to the Priority Health Behavioral Health Department.
Medicaid authorization and payment questions
The Michigan Department of Community Health has created a chart listing authorization and payment responsibilities by type of service and place of service.
Coordination between PCPs and behavioral health providers
Primary care providers and behavioral health specialists should use the Priority HealthCoordination of Care (COC) form to communicate:
- Requests for consultations
- Medication management or therapy
- Dates of behavioral health sessions
Behavioral health services
- 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