Behavioral Prior Authorization - Community Health Plan of Washington - Medicare Advantage

Behavioral Prior Authorization

Treatment for behavioral health issues may require prior authorization or notification. Members will need referrals for intensive care management services for high-intensity Outpatient programs. Initial assessment and outpatient and referrals are done on a case by case basis.

  • All billed services must meet medical necessity requirements, regardless of authorization requirements.
  • All services provided by a non-contracted provider require Prior Authorization.

Review the behavioral health utilization guidelines for an overview of services that require prior authorization.
2019 Behavioral Health Utilization Guidelines.

Emergency Services Do Not Require Prior Authorization

Emergency services for behavioral health are defined in the following way.

Psychiatric: When the patient is a danger to themself, others, or is gravely disabled.

Medical: A medical condition with acute symptoms of sufficient severity that the absence of immediate medical attention may result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, or serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

For inpatient hospitalization and high-intensity outpatient programs, notification is required.

Inpatient Hospitalization Psychiatric & Substance Use Disorder (SUD) Inpatient Services

Types of Services:

  • Acute Psychiatric Inpatient Care
  • Evaluation &Treatment Admission
  • Inpatient Acute Withdrawal (Detoxification)
  • Crisis Stabilization in residential setting
  • Inpatient Rehab, Substance Use Disorder (SUD)
  • Inpatient residential treatment center, psychiatric
  • Inpatient residential treatment center, SUD
  • Any facility-based service providing 24 hours/day and 7days/week services.

High Intensity Outpatient Programs

Notification required for initial 6 months, followed by ongoing concurrent review and authorization to extend past the 6 months.

Types of Services:

  • Partial Hospitalization Program (PHP)
  • Day Treatment Program
  • COMET Program

General Requirements

  • All clinical trials require approval
  • All inpatient and outpatient substance use disorder treatment for Medicare patients requires prior authorization.
  • All unlisted codes with a charge greater than $500 require a prior authorization

Mental Health Services

  • Elective Inpatient Psychiatric Services (Integrated Managed Care/BHSO)
  • Electroconvulsive Therapy
  • Repetitive Transcranial Magnetic Stimulation (RTMS)
  • Neuropsychological Testing and Psychological Testing

Psychological and Neuropsychological Testing requires prior authorization.

➔ Download the request form before administering treatment

Clinical Coverage Criteria

MM129 Neuropsychological Testing Clinical Coverage Criteria
MM132 Complementary Alternative Care
MM171 Inpatient Rehabilitation
MM176 Psychological Testing

DID YOU KNOW...?

Required Training

Providers are required to complete a Fraud, Waste, and Abuse training within 90 days of contracting with CHPW and annually thereafter. All clinic staff – including CEOs, senior leaders, managers, clerical/admin staff, physicians, and other clinical staff – are required to receive this training. Training courses are available on the CMS Medicare Learning Network website.

More information can be found in our Provider Manual.

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