Members do not need a referral from their Primary Care Provider (PCP) to see a behavioral health provider. We encourage all providers to call us in advance of providing services to confirm the member’s eligibility, the in-network status of the facility and to verify benefits.
To verify member’s eligibility, the in-network status of the facility, verify benefits and for prior-authorization requests and other related clinical questions, please call 1-800-682-9094. For authorization requests, please call within 24 hours of the admission and provide the reason for the admission, diagnosis, medication, treatment plan, discharge plan and any other pertinent information we would need for medical necessity review.
Authorization is available 24 hours a day, seven days a week. Non-emergent behavioral health services are available Monday to Friday from 8 a.m. to 5 p.m., Eastern Time.
For substance use disorder services for individuals who are not MLTSS, DDD or FIDE-SNP members, contact IME Addiction Access Center at 1-844-276-2777, 24 hours a day, seven days a week.
Prior authorization is not required for outpatient services for in-network providers. Prior authorization and a single case agreement are required for out-of-network providers. Criteria for single case agreement will be discussed during the review for authorization.
The following behavioral health services require prior-authorization for both in network and out of network providers:
- Inpatient Psychiatric Treatment
- Residential Mental Health
- Partial Hospitalization (PHP)
- Partial Care
- Intensive Outpatient (IOP)
- Adult Mental Health Rehabilitation (AMHR) Group Homes and Apartments
- Psychological Testing
- Repetitive Transcranial Magnetic Stimulation (rTMS)
- Electroconvulsive Therapy (ECT)
- Medically Managed Detox (ASAM 4.0)
- Medically Monitored Detox (SUD ASAM 3.7D)
- Inpatient SUD Rehab (ASAM 3.7)
- Residential SUD (ASAM 3.5)
- Partial SUD (ASAM 2.5)
- IOP SUD (ASAM 2.1)
- Applied Behavior Analysis (ABA)
- Developmental, Individual-differences and Relationship-based Model (DIR)
- All out-of-network providers will require an authorization for any level of care including outpatient levels of care.