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.
Emergency Services Do Not Require Prior Authorization
Emergency services for behavioral health are defined the following way.
Psychiatric: When the patient is a danger to them self, 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
- 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.
Clinical Coverage Criteria