Partial hospitalization and intensive outpatient services for substance use disorders

Coverage varies by member plan. Medicare Advantage plans don't cover day programs, but may cover components of a day program.

Applies to:

Group HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO 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 partial hospitalization and intensive outpatient treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:

Medical Necessity - 91447

Mental Health Residential Treatment, Adult - 91608

Mental Health Residential Treatment, Child and Adolescent - 91607

Authorization is required

Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for partial hospitalization and intensive outpatient programs.

You must request authorization prior to sending a member to these programs. 

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