Mental health inpatient authorizations

Coverage varies depending on plan.

Applies to:

Group HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO plans

Medicare Advantage plans

Definition

When a member is admitted to a mental health facility as an inpatient for behavioral health 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 inpatient treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:

Medical Necessity - 91447

Eating Disorders - 91007

Authorization is required

Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for urgent/emergent admission to mental health facilities.  When a member is admitted as an inpatient, request authorization using this form:

Behavioral Health Inpatient Authorization Request form

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

Information needed to authorize services:

  • Stressors/symptoms
  • Psychosocial information
  • Pertinent treatment history
  • Risk factors
  • Recommendation