Behavioral Health Prior Authorization

Behavioral health prior authorization

Some treatments for behavioral health services will require prior authorization. Members will need prior authorization for some high-intensive outpatient service, clinical testing, and mental health residential care. All billed services requiring prior authorization must meet medical necessity and will need to go through the prior authorization process.

• All billed services must meet medical necessity requirements, regardless of authorization requirements.

Review the behavioral health utilization guidelines for an overview of services that require prior authorization.

➔ Behavioral Health Prior Authorization List and Utilization Guideline

Inpatient hospitalization psychiatric and 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 7 days/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
• PACT Program
• COMET Program

General requirements for prior authorization:

• 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 $250 require a prior authorization

Mental health services:

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

Psychological and neuropsychological testing requires prior authorization.

Resources and Forms

Online prior authorization portal (JIVA)

We prefer that you submit prior authorizations through our Care Management Portal (JIVA). By using the portal, you can check eligibility and authorization status, print approval letters, and submit requests online 24/7. For registration Issues or technical assistance contact Portal Support at portal.support@chpw.org.

➔ Access Portal
➔ Request Portal Account

Fax prior authorization and notification forms

If you prefer to fax your prior authorization requests, fill out the appropriate form and fax it to the number listed on the form.

• Exception to the Rule Request form
• Express Scripts Pharmacy forms
• Inpatient Admission form
• Mental Health Service Request form
• ABA Therapy Initial Request form
• Psych/Neuropsych Testing Request form
• Substance Use Disorder Services Request form
• Limitation Extension Request form
• Prior Authorization Request form
• WISe Services Change Notification form

If you do not see the appropriate form on this list, please check our Forms and Tools page or contact customer service.

Clinical Coverage Criteria

• Clinical Coverage Criteria
• MCG Criteria
• LOCUS document
• CALOCUS document
• ASAM