Medicaid behavioral health services

Applies to:

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:

Coding help

The specific code set to be billed to the proper PIHP can be found by logging into CHAMPS:

  1. Go to the External Links menu located on the 'Provider Portal' page.
  2. Select 'Medicaid Code and Rate Reference' from the dropdown list.

Medicaid resources

Below are links to information on substance use disorders and on acute detoxification:

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.

Open the Medicaid Mental Health Substance Use Disorder Authorization and Payment Responsibility Grid.