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Coverage criteria policies

Adult mental health residential services coverage criteria

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

This coverage policy is only applicable to those plans that cover adult mental health residential treatment.  See your plan documents for more information. 

All residential services require prior authorization.

Please contact the Behavioral Health Department at 952-883-7501 for authorization or fax clinical to 952-853-8830.

Coverage

HealthPartners follows the MCG Health Behavioral Health Care 22nd Edition Copyright © 2018 MCG Health, LLC. Please contact the Behavioral Health Department at 952-883-7501 for a copy.

Adult MH residential treatment is only covered subject to your plan documents.

A diagnostic assessment and relevant clinical information must be reviewed by a Behavioral Health Coordinator and a board certified Psychiatrist and prior authorization obtained prior to admission for residential care.

Indications that are not covered

  1. Member does not meet DSM-5 diagnostic criteria for a mental health disorder
  2. Clinical information submitted and reviewed does not meet the MCG Coverage Criteria for the requested level of care.
  3. Services do not meet the definition of medical necessity in the member’s plan.
  4. Member’s plan does not cover services requested.

Definitions

Residential: Provides 24 hour, structured and supervised treatment for members who have not responded to lower levels of care. Residential care is intended for patients who need around-the-clock behavioral care but do not need the level of physical security and high frequency of psychiatric and medical intervention that are available on an inpatient unit.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. MCG Health Behavioral Health Care 22nd Edition Copyright © 2018 MCG Health, LLC Last Update: 1/30/2018 6:35:15 PM - Build Number: 22.0.99237.004578

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Policy activity

  • 05/08/2018 - Date of origin
  • 09/01/2018 - Effective date

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