Request TP/PIHP authorization within 72 working hours; observe 15‑day monthly authorization limits

Contact the Tailored Plan/Prepaid Inpatient Health Plan (TP/PIHP) utilization review contractor to request authorization within 72 working hours of admission. Initial authorizations average ~7 days; no more than 15 days may be authorized in a single calendar month for psychiatric treatment (the 15-day monthly limit may be exceeded for substance use disorder treatment). For admissions spanning two months, up to 15 days may be authorized each month (allowing up to ~30 calendar days across the two months).

• Authorization request must be submitted to the TP/PIHP within 72 working hours of admission.
• Initial authorization typically ~7 days; concurrent authorization based on medical necessity.
• Limit of 15 authorized days per calendar month for psychiatric treatment; exceptions for SUD and consecutive-month admissions described in policy.

Confirm member meets the listed preadmission clinical criteria before admission

Ensure the member meets preadmission review clinical criteria before admission: for substance use disorders, one of the listed SUD criteria (e.g., need for medical detoxification, risk of convulsions/delirium tremens, need for skilled observation, danger to self/others, or significant medical/psychiatric disorder). For non‑substance psychiatric diagnoses, one of the listed criteria must be present (e.g., impaired reality testing, danger to self/others, severe functional impairment, failure of less‑restrictive treatments, need for skilled observation or special procedures).

• SUD admission criteria include need for skilled observation or therapeutic milieu, medical detoxification not manageable by alternatives, imminent convulsions/delirium/psychosis, danger to self/others not manageable by alternatives, or significant medical/disabling psychiatric disorder.
• Non‑SUD psychiatric criteria include impaired reality testing, disordered behavior, danger to self/others, concomitant severe medical illness or SUD, severely impaired functioning not treatable by alternatives, failure of alternative treatments, or need for skilled observation/special diagnostics or therapeutic milieu.

Complete service order on or before first day and submit medical records/MID when eligibility is pending

Complete and submit required documentation per Medicaid and TP/PIHP rules: a signed service order by an authorized clinician must be completed prior to or on the first day of service, and hospitals must send the patient's medical record and obtain/submit the MID number when eligibility is pending or applied during/after the stay.

• Service order must be completed by a physician, licensed psychologist, physician's assistant, or nurse practitioner per scope of practice prior to or on the first day of service.
• If Medicaid eligibility is pending or applied during/after stay, hospitals must send the complete medical record to the TP/PIHP utilization review contractor within required timeframes and obtain/submit the MID number with the record.

Denial risk if medical necessity, prior authorization, or Medicaid submission rules are not followed

Non‑payment or denial can occur if medical necessity criteria, prior authorization, or Medicaid submission rules are not followed; hospitals must contact the TP/PIHP utilization review contractor within 72 working hours for emergency admissions or risk non‑reimbursement if MID numbers or timely records are not provided.

• Services are not covered when medical necessity criteria for admission or continued stay are not met.
• Failure to obtain required prior authorization within 72 working hours for Medicaid admissions or failure to obtain/submit the MID number and timely medical records can result in non‑payment.