Detoxification services authorizations

Coverage varies by member plan.

Applies to:

Group HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO plans

Medicare Advantage plans

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 substance use disorder detox the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:

Medical Necessity - 91447

Detoxification - 91104

Auth is required

To admit a member as an inpatient for substance use disorder detoxification treatment, use the Behavioral Health Inpatient Authorization Request form. 

Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for urgent/emergent admission to a substance use disorder facility. 

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

Information needed

  • Legal involvement related to substance use
  • Age of first use
  • Age that substance use became problematic
  • Type of substances used
  • Frequency and amount
  • Current vital signs
  • Risk factors
  • Recommendation

Behavioral health fax process

Send a separate fax for each individual patient. Faxes referencing more than one patient will be returned for resubmission.

  1. Complete the form for the service you're requesting and use it as the cover sheet for your fax.
    Inpatient Prior Authorization Form  or  Outpatient Service Request Form
  2. Identify the evaluating facility/agency contact's name and phone number on the auth form/cover sheet.
  3. Attach complete clinical notes or the screening form to ensure that we have all available clinical data to review.

Requirements for clinical notes

Computer-generated or typewritten notes are preferred. Hand-written documentation may delay the review process and require extra phone calls to clarify information and clinical content. 

Include:

  • CIWA or COWS score if available
  • All vitals including blood pressure, pulse, temperature and respirations
  • Any specific withdrawal symptoms that the patient is currently exhibiting
  • The specific dates of any transfers from one level of service to another

Response turnaround times

We don't typically process requests during the lunch hour, but a requesting facility will receive a response fax within 1 business day.

  • Fax us before 11:00 a.m. - Same-day response
  • Fax us after 2:00 p.m. - Response by 11:00 a.m. next business day
  • Fax us after 4:00 p.m. - Response by 2:00 p.m. next business day