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.
• 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.

➔ Behavioral Health Prior Authorization List and Utilization Guidelines

Procedure Code Lookup Tool 

Inpatient hospitalization psychiatric and substance use disorder (SUD) inpatient services

Types of services:

• Acute Psychiatric Inpatient Mental Health
• Electroconvulsive therapy (ECT)
• Evaluation & Treatment
• Inpatient Acute Substance Abuse Withdrawal Management (Detoxification)
• Psychological and neuropsychological testing
• Repetitive Transcranial Magnetic Stimulation (RTMS)
• Crisis Stabilization in a residential setting
• Substance Use Disorder inpatient rehabilitation and residential treatment center
• Psychiatric inpatient residential treatment center

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)

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
• Electroconvulsive Therapy (ECT)
• Repetitive Transcranial Magnetic Stimulation (RTMS)
• Psychological and neuropsychological 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.

• 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 
• Prior Authorization Request form

If you do not see the appropriate form on this list, please contact CHPW Customer Service.

Clinical Coverage Criteria

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