PH - Prior Auth Requirement for Outpatient Behavioral Health Changes

November 12, 2019

Effective Jan. 1, 2020, Medicaid outpatient behavioral health therapy will no longer require prior authorization. You will no longer need to submit clinical documentation for these requests.

Why we’re making this change

We’re removing the authorization requirement to improve members' access to the mental health services they need to ensure they’re able to get the right care at the right time.

Helping your Medicaid patients get the behavioral health care they need

Refer your patients to a Priority Health in-network behavioral health provider

We’re responsible for reimbursement for outpatient behavioral health therapy services for Medicaid members with mild to moderate mental health needs. This includes patients experiencing or demonstrating mild to moderate psychiatric symptoms or signs of sufficient intensity to cause subjective distress or mildly disordered behavior, with minor or temporary functional limitations or impairments and minimal clinical instability.

Refer your patients to Community Mental Health (CMH) when they have:

  • Severe mental illness, serious emotional disturbance (children and adolescents), or those with a developmental disability. Patients appropriate for CMH services often have substantial impairment in their ability to perform daily living activities, including bathing, dressing, personal hygiene, preparing meals, housework and employment. For children and adolescents, this includes interference in achievement or maintenance of developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills
  • Functional impairment that is significant or long-term in nature or is already receiving case management, support coordination, or home-based services from CMH.
  • Substance abuse disorders
  • Autism   

How services will be monitored

A clinical review process may be initiated for patients with high utilization of outpatient services. Behavioral Health providers will be contacted, and a request will be made to submit clinical documentation for review. This process will be used to review the clinical needs of your patient and determine if specialty mental health services from CMH would be clinically appropriate. 

Important: Medicaid patients already receiving outpatient behavioral health therapy services will not need to have updated or terminated authorization. Our claims system will not require authorization; therefore, claims will process automatically.

Resources to help you determine where your patient should receive services

An additional resource you can hand out to your patients is the Getting Services Flyer