Behavioral Health Services Prior Authorizations

Behavioral health prior authorization forms

• Neuropsychological Testing Request/Psychological Testing Request. (PDF)
  Use this form to request prior authorization for outpatient treatment.
• Behavioral Health Outpatient Treatment Request Form. (PDF)
  Use this form to request neuropsychological and psychological testing.

How to submit requests for behavioral health prior authorization

For the initial prior authorization of inpatient stays and electroconvulsive therapy programs, please submit requests by one of the following methods. Requests to extend authorization on these services may also be submitted by phone.

• Phone: Call Keystone First VIP Choice Behavioral Health Utilization Management at 1-866-688-1137.
• Fax: 1-855-396-5740, or fill out and submit our Behavioral Health Clinical Fax Form (PDF).

Behavioral health services requiring prior authorization

The following is a list of behavioral health services requiring prior authorization review for medical necessity and place of service:

• Mental health partial hospitalization program.
• Inpatient detoxification admissions.
• Mental health inpatient admissions.
• Neuropsychological testing.
• Psychological testing.
• Electroconvulsive therapy (inpatient or outpatient).

Behavioral health services that do not require prior authorization

• Outpatient behavioral health counseling and therapy.
• Outpatient evaluation.
• Outpatient medication management services.
• Outpatient nursing services.

Covered behavioral health services

• Diagnostic and assessment services.
• Physician and mid-level practitioner visits.
• Individual counseling, group counseling, family counseling and federally qualified health center (FQHC) services.
• Medication management.
• Inpatient acute psychiatric hospitalization and emergency services.
• Partial hospitalization services.

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