ModifiedSecurity Health Plan of Wisconsin, Inc.Policy N/A

Behavioral Health/Substance Use Disorder (SUD) Treatment

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This policy governs coverage, utilization management, prior authorization, notification, and program-specific limitations for mental health and substance use disorder services across Security Health Plan commercial, Medicaid, Family Health Center, Medicare Advantage, and third-party administration products.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBehavioral Health/Substance Use Disorder (SUD) Treatment

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionFor commercial members, prior authorization is required for all non-affiliated providers and facilities.

SourceLink

POLICY UPDATE CHANGES

April 2026 updates added Recovery Support Services information to the BadgerCare section.

January 2026 updates deleted duplicate ForwardHealth information for substance abuse.

March 2024 updates added a Medicaid section addressing court-ordered inpatient or institutionalized behavioral health services.

March 2024 updates revised the Medicaid residential behavioral health treatment section.

December 2020 updates added residential substance use treatment information under BadgerCare and required notification when residential services are covered for SAS.

January 2025 updates revised BadgerCare intensive outpatient, outpatient substance use disorder, and outpatient mental health information.

February 2023 updates classified Prescription Digital Therapy as experimental and investigational based on a technology assessment.

5/1/2026Current effective date

24/7Residential treatment availability

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ModifiedSecurity Health Plan of Wisconsin, Inc.Policy N/A

Behavioral Health/Substance Use Disorder (SUD) Treatment

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBehavioral Health/Substance Use Disorder (SUD) Treatment

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionFor commercial members, prior authorization is required for all non-affiliated providers and facilities.

SourceLink

POLICY UPDATE CHANGES

April 2026 updates added Recovery Support Services information to the BadgerCare section.

January 2026 updates deleted duplicate ForwardHealth information for substance abuse.

March 2024 updates added a Medicaid section addressing court-ordered inpatient or institutionalized behavioral health services.

March 2024 updates revised the Medicaid residential behavioral health treatment section.

December 2020 updates added residential substance use treatment information under BadgerCare and required notification when residential services are covered for SAS.

January 2025 updates revised BadgerCare intensive outpatient, outpatient substance use disorder, and outpatient mental health information.

February 2023 updates classified Prescription Digital Therapy as experimental and investigational based on a technology assessment.

5/1/2026Current effective date

24/7Residential treatment availability

No PACommercial IOP, CSP, and crisis intervention requirements

4/1/2026Medicaid peer recovery support services

Not coveredMedicaid institutionalized behavioral health over age 21

AllNon-affiliated provider and facility authorization

Coverage by Product and Service

Commercial Behavioral Health and SUD Services

For commercial members diagnosed with a mental health or substance use disorder, the following behavioral health and SUD services are covered subject to applicable plan requirements.

Commercial coverage requirements

Covered service categories
- Residential treatment, which evaluates and stabilizes the member, teaches coping strategies, supports transition to outpatient care, and generally provides treatment 24 hours per day, 7 days per week.
- Day treatment or partial hospitalization (PHP), a medically monitored, nonresidential service consisting of regularly scheduled individual, group, or family counseling and case management under physician supervision.
- Intensive outpatient program (IOP), a structured program addressing mental health or substance use disorders through a combination of individual, group, and family therapy.
- Community Support Programs (CSP), coordinated treatment, rehabilitation, and support services delivered through an identified program and staff for persons with chronic mental illness.
- Crisis intervention, consisting of immediate evaluation and mental health care for persons experiencing a mental health crisis and available 24 hours per day, 7 days per week.
Prior authorization is required for all non-affiliated providers and facilities.
Notification of admission is required for residential treatment.
No prior authorization or clinical review is required for day treatment, IOP, CSP, or crisis intervention services.

BadgerCare Plus and Medicaid SSI

BadgerCare Plus and Medicaid SSI coverage is administered under the HMO contract and applicable ForwardHealth requirements.

Medicaid behavioral health coverage framework

Under the BadgerCare Plus HMO contract, the Health Plan will not be more restrictive than FFS Medicaid.
Payable services, provider types, specialties, and places of service are determined through the ForwardHealth interactive fee schedule and applicable ForwardHealth handbooks, updates, and contracts.
For adults, adolescents, and children, the Medicaid HMO does not require prior authorization for outpatient day treatment, PHP, IOP, or outpatient mental health or substance use disorder services.
For intensive in-home mental health and substance abuse treatment services for children and adolescents, providers must follow HealthCheck ‘Other Services’ Medical Policy.

Court-Ordered and Emergency Services

The following services are covered under the Medicaid HMO contract when legally required; medical necessity is presumed for specified court-ordered and emergency services.

Court-ordered and emergency services

Covered legally mandated services
- Examination and treatment services, provided by adequately experienced providers, for members who are victims of child abuse, incest, or neglect; members diagnosed with post-traumatic stress syndrome; members who are victims of domestic violence; and perpetrators of child abuse, incest, neglect, or domestic violence.
- Court-ordered physical, psychological, mental, or developmental examinations and medical or psychiatric treatment for victims and perpetrators of child abuse and neglect.
- Assessments under the Children's Code, Wis. Stats. s. 48.295, and medically necessary treatment resulting from those assessments.
- Medically necessary substance abuse treatment ordered in a member’s Driver Safety Plan under Wis. Stats. ch. 343 and Wis. Admin. Code ch. DHS 62.

Court-Ordered Inpatient or Institutionalized Behavioral Health Services

Medicaid coverage for court-ordered inpatient or institutionalized behavioral health services depends on the member’s age and the Medicaid Institution for Mental Diseases (IMD) restrictions.

Covered circumstances

The member is under age 21; services are covered by the Health Plan under the HMO contract. If notified, the Health Plan may request use of a PAR provider. If the Health Plan does not provide feedback, it remains responsible for coverage regardless of which facility the court selects.
The member was an IMD resident immediately before turning 21 and remained continuously resident through the member’s 22nd birthday.
The member is age 21 and an IMD resident; coverage may continue only until the member’s 22nd birthday.

Residential Behavioral Health Treatment

Medicaid residential behavioral health treatment coverage differs by service type and member age.

Residential treatment coverage

Residential substance use disorder treatment is covered by ForwardHealth for dates of service on or after 02/01/21. Prior authorization and claims are submitted directly to Fee-for-Service Medicaid.
Residential behavioral health treatment for persons under age 21 may be considered under HealthCheck ‘Other Services’; prior authorization is required.
Residential behavioral health treatment for persons over age 21 is not covered.

Medicaid Outpatient and Community Services

Medicaid outpatient and community behavioral health services follow ForwardHealth coverage requirements and applicable HMO contract provisions.

Covered outpatient and community services

Service coverage
- Transportation for day treatment for Medicaid and BadgerCare Plus members is handled through the non-emergent medical transportation (NEMT) manager.
- IOP services are covered consistent with ForwardHealth; the Health Plan does not require prior authorization for IOP services.
- Peer Recovery Support Services are covered for dates of service on and after 04/01/26.
- Outpatient substance use disorder services are covered according to the ForwardHealth Outpatient Substance Abuse Handbook and its covered-service requirements.

Family Health Center Behavioral Health Coverage

Family Health Center Member Handbook coverage applies to the following behavioral health services.

Covered Family Health Center services

Day treatment for behavioral health, including care for mental health and substance misuse, is covered; no prior authorization or clinical review is required.
IOP for behavioral health, including care for mental health and substance misuse, is covered; no prior authorization or clinical review is required.
CSP services for behavioral health, including care for mental health and substance misuse, are covered; no prior authorization or clinical review is required.

All Certificate limitations and exclusions apply to commercial coverage.

Prescription digital therapy is experimental and investigational based on the technology assessment completed in February 2023.

For persons over age 21, court-ordered inpatient or institutionalized behavioral health services are not covered. Wisconsin Medicaid does not reimburse services to a person 21 to 64 years of age who is a resident of an IMD, except when the member was an IMD resident immediately before turning 21 and remains continuously resident through the 22nd birthday, or when a 21-year-old IMD resident is covered only until the 22nd birthday.

Residential behavioral health treatment is not covered for persons over age 21.

For residential behavioral health treatment for persons under age 21, room and board is not covered. Providers must obtain a written, signed, and dated agreement stating that room and board is excluded and that the member is fully responsible for payment. The agreement must be provided to the member and retained in the provider’s records.

Per the Family Health Center Member Handbook, residential treatment and crisis intervention services are not covered.

Authorization, Notification, and Documentation

Prior Authorization

Commercial Authorization and Residential Notification

Prior authorization is required for all behavioral health and substance use disorder services provided by non-affiliated providers and facilities. For covered residential services, the provider or facility must notify the Health Plan of the admission.

Commercial: Non-affiliated provider and facility services require prior authorization.
Residential: Notification of admission is required.

Note

Medicaid Outpatient Services

For BadgerCare Plus and Medicaid SSI members, the Health Plan Medicaid HMO does not currently require prior authorization for outpatient day treatment, PHP, IOP, or outpatient mental health or substance use disorder services for adults, adolescents, or children.

Verify payable services, provider types, specialties, and places of service through the ForwardHealth interactive fee schedule.

Policy Scope

This policy addresses the continuum of behavioral health and substance use disorder services, from outpatient care through crisis intervention, intensive outpatient programs, partial hospitalization or day treatment, community support programs, and residential treatment. Residential programs provide 24-hour-per-day, 7-day-per-week care focused on evaluation, stabilization, coping skills, and transition to outpatient services. Mental health and substance use disorder conditions are defined using the most current DSM and applicable federal and state law.

Behavioral Health Service Definitions

Transitional care

Relative intensityServices that are not as intensive as hospital inpatient care but are more intensive than outpatient care.

Included servicesTransitional care includes certified residential treatment programs, intensive outpatient programs, certified community support programs, certified day treatment programs, and crisis intervention services.

Care continuumTransitional care provides an intermediate level of behavioral health and substance use disorder services between outpatient and hospital inpatient care.

Residential treatment

Primary purposeResidential treatment focuses on evaluating and stabilizing the patient and helping the patient learn effective ways to cope with the symptoms and impact of the illness.

Treatment setting

Level-of-Care Coverage Framework

Residential Level-of-Care Criteria

Residential treatment is appropriate when the member requires a 24-hour treatment setting to evaluate and stabilize the condition and prepare for transition to outpatient care.

Residential treatment level: Residential treatment is used to evaluate and stabilize the patient, provide coping support, and prepare for transition to outpatient services in a 24-hour-per-day, 7-day-per-week program.24 hours per day, 7 days per week

Residential admission notification is required for commercial members and TPA members when residential services are covered.

Partial Hospitalization Program/Day Treatment Level-of-Care Criteria

Partial hospitalization or day treatment is appropriate when medically monitored, nonresidential treatment is required under physician supervision.

Partial hospitalization/day treatment level: Day treatment or PHP is a medically monitored, nonresidential service with regularly scheduled individual, group, or family counseling and case management under physician supervision to address a mental health or substance use disorder.

Covered Treatment Modalities

Residential Treatment Modality Criteria

Residential treatment includes all of the following treatment components.

Residential treatment: Residential services focus on evaluation and stabilization, development of effective coping skills, and transition to outpatient services in a 24-hour-per-day, 7-day-per-week setting.24 hours per day, 7 days per week

Notification of admission is required where specified by the member's product.

Day Treatment/Partial Hospitalization Modality Criteria

Day treatment or PHP includes all of the following treatment components.

Day treatment/PHP: Day treatment or PHP consists of regularly scheduled individual, group, or family counseling and case management under physician supervision in a medically monitored, nonresidential setting for a mental health or substance use disorder.

Authorization requirements vary by product and, for Medicaid, by member age and applicable ForwardHealth requirements.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyBehavioral Health/Substance Use Disorder (SUD) Treatment

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionFor commercial members, prior authorization is required for all non-affiliated providers and facilities.

SourceLink

On This Page

Emergency detention and court-ordered services during an emergency detention, including services provided by out-of-network providers.

The medical necessity of court-ordered evaluation and treatment is assumed to be established.

The medical necessity of services specified in a Driver Safety Plan is assumed to be established.

The HMO may provide treatment through its network, but cannot withhold or limit court-ordered services unless or until the court agrees to the withholding or limitation.

For a written referral or request for treatment authorization, the HMO must respond within five days. Authorization is retroactive to the date of the request; after five days, the provider may assume the service is authorized until the HMO responds in writing.

During emergency detention, care is presumed medically necessary and the HMO must cover care provided before the emergency-detention probable-cause hearing.

The HMO is not liable for substance abuse educational programs or the initial assessment used to develop a Driver Safety Plan.

Outpatient mental health services are covered according to the ForwardHealth Outpatient Mental Health Handbook.

CSP services are covered by FFS Medicaid under the ForwardHealth HMO Contract.

Crisis intervention services are covered by FFS Medicaid under the ForwardHealth HMO Contract.

For intensive in-home mental health and substance abuse treatment for children and adolescents, follow HealthCheck “Other Services” requirements.

Unsupported block type: prior_auth

Prior Authorization

Under-21 Residential Authorization

For Medicaid members under age 21, residential behavioral health treatment may be considered under HealthCheck “Other Services.” Prior authorization is required.

Follow HealthCheck “Other Services” authorization requirements.
Residential treatment for members over age 21 is not covered.

Prior Authorization

Adult Mental Health Day Treatment

ForwardHealth may require prior authorization for adult mental health day treatment. Providers must check the ForwardHealth Handbook for codes requiring authorization and for covered-service requirements.

Navigate to BadgerCare Plus & Medicaid > Adult Mental Health Day Treatment > Covered and Noncovered Services > Codes > Procedure Codes.
Use the Covered Services and Requirements section to confirm coverage.

Prior Authorization

Child and Adolescent Day Treatment

ForwardHealth requires prior authorization for child and adolescent mental health day treatment. Providers must submit according to HealthCheck “Other Services” and ForwardHealth requirements.

Navigate to BadgerCare Plus & Medicaid > Child/Adolescent Day Treatment, HealthCheck “Other Services” > Covered and Noncovered Services > Codes > Procedure Codes.
Use Covered Services and Requirements to confirm coverage and submission requirements.

Prior Authorization

Substance Abuse Day Treatment

Substance abuse day treatment may require prior authorization. Providers must check the ForwardHealth Handbook for procedure codes requiring authorization and for covered-service requirements.

Navigate to BadgerCare Plus & Medicaid > Substance Abuse Day Treatment > Covered and Noncovered Services > Codes > Procedure Codes.
Use the Covered Services and Requirements section to confirm coverage.

Note

Medicaid IOP Authorization Exception

The Health Plan follows ForwardHealth coverage for Medicaid Intensive Outpatient Program services, but Health Plan prior authorization is not required for these services.

Follow applicable ForwardHealth coverage and billing requirements.
See ForwardHealth Update 202438, “New Intensive Outpatient Program Benefit,” for program information.

Denial Risk

Family Health Center Coverage Rules

For Family Health Center members, behavioral health and substance misuse day treatment, behavioral health IOP, and CSP are covered without prior authorization or clinical review. Residential treatment and crisis intervention services are not covered.

Covered without prior authorization or clinical review: Day treatment, behavioral health IOP, and CSP.
Not covered: Residential treatment and crisis intervention services.

Prior Authorization

TPA Authorization and Residential Notification

For TPA groups, prior authorization is required for all services provided by non-affiliated providers and facilities. If residential services are covered under the member’s plan, notification of admission is required.

Review the member’s Summary Plan Description to determine coverage, limitations, and exclusions.
If the Summary Plan Description lacks specific guidelines or criteria, TPA groups using the Health Plan to process services follow commercial criteria.

Prior Authorization

Non-Affiliated Provider Authorization

Non-affiliated providers must obtain prior authorization for behavioral health and substance use disorder treatment unless a specific applicable benefit rule states otherwise.

Confirm whether the provider or facility is affiliated before rendering services.
For covered residential services, also notify the Health Plan of admission.

Documentation Required

Verify Member-Specific Benefit Documents

Before determining coverage or submitting authorization, verify the member-specific benefit documents that apply to the member and product.

Review the applicable Schedule of Benefits and Certificate.
For TPA members, review the Summary Plan Description.
Apply the applicable Member Handbook or other product-specific benefit document.

Documentation Required

Certification of Need for Residential Admission

For Medicaid members under age 21 whose residential behavioral health treatment may be considered under HealthCheck “Other Services,” the Health Plan recommends completing and submitting the Wisconsin DHS Certification of Need for Elective/Urgent Psychiatric/Substance Abuse Admissions to Hospital Institutions for Members Under Age 21.

The form is available through ForwardHealth Topic 1411, “Institution for Mental Disease Services.”

Documentation Required

Residential Room and Board Agreement

For Medicaid members under age 21 receiving residential behavioral health treatment, room and board is not covered. The provider must arrange a written payment agreement with the member.

The agreement must specifically state that room and board is not covered and that the member is fully responsible for payment.
The agreement must be signed and dated by the provider and member.
Provide a copy to the member and retain a copy in the provider’s records.

Documentation Required

Residential Admission Notification

Notify the Health Plan of a residential admission when residential services are covered under the member’s plan.

The notification requirement applies to covered residential services for applicable commercial, TPA, and other member plans.

Denial Risk

Prescription Digital Therapy

Prescription digital therapy is experimental and investigational based on the February 2023 technology assessment.

Do not treat prescription digital therapy as a covered benefit without confirming applicable plan provisions.

Denial Risk

Medicaid Institutionalized Behavioral Health Over Age 21

Court-ordered inpatient or institutionalized behavioral health services for Medicaid members over age 21 are not covered, subject to the ForwardHealth institutionalized-services rules and exceptions.

For members under age 21, court-ordered inpatient or institutionalized behavioral health services are covered under the Health Plan HMO contract.
Emergency detention services before the probable cause hearing are treated as medically necessary under the stated Medicaid requirements.

Denial Risk

Medicaid Residential Behavioral Health Over Age 21

Residential behavioral health treatment for Medicaid members over age 21 is not covered.

Confirm the member’s age and applicable Medicaid benefit category before admission or billing.

Denial Risk

Residential Room and Board Exclusion

For Medicaid members under age 21, residential treatment room and board is not covered and remains the member’s responsibility under a signed written agreement.

The agreement must identify room and board as excluded from coverage and state that the member is responsible for payment.
The provider must retain the signed and dated agreement and provide a copy to the member.

Denial Risk

Family Health Center Excluded Services

Under the Family Health Center Member Handbook, residential treatment and crisis intervention services are not covered.

Do not submit residential treatment or crisis intervention services as covered Family Health Center benefits.
Day treatment, behavioral health IOP, and CSP have separate covered-service provisions and do not require prior authorization or clinical review.

Residential programs provide treatment 24 hours per day and 7 days per week.

Transition goalPatients stay as needed to prepare for a successful transition into outpatient services.

Day treatment service/Partial Hospitalization Program (PHP)

SettingA medically monitored, nonresidential treatment service.

Treatment modalitiesConsists of regularly scheduled individual, group, or family counseling sessions and case management.

Supervision and conditions addressedServices are provided under the supervision of a physician to address mental health or substance use disorders.

Intensive Outpatient Program (IOP)

Program typeA structured program addressing mental health or substance use disorders.

Therapy componentsTreatment consists of a combination of individual, group, and family therapy.

Care levelIntensive outpatient care is structured treatment provided outside a residential setting.

Community Support Program (CSP)

Program purposeA coordinated care and treatment program providing treatment, rehabilitation, and support services.

Delivery modelServices are provided through an identified treatment program and staff to ensure ongoing therapeutic involvement and individualized services in the community.

Population servedThe program serves persons with chronic mental illness in the community.

Crisis intervention service

Core serviceImmediate evaluation and mental health care for persons experiencing a mental health crisis.

Available settingsServices may be provided through county mental health outpatient programs, mental health inpatient programs, or mental health day treatment programs.

AvailabilityServices are available 24 hours a day, 7 days a week.

StaffingThe program is staffed by mental health professionals, paraprofessionals, or trained mental health volunteers backed up by mental health professionals.

Mental health and substance use disorder conditions

Mental health conditionsMental health conditions are defined by the most current version of the DSM.

Substance use disordersSubstance use disorders are defined by the most current version of the DSM.

Benefit alignmentMental health and substance use disorder benefits are provided for covered items or services in accordance with applicable federal and state law.

Commercial day treatment does not require prior authorization or clinical review; Medicaid authorization depends on the applicable ForwardHealth program and member age.

Intensive Outpatient Program Level-of-Care Criteria

Intensive outpatient treatment is appropriate when a structured combination of therapies is required without residential care.

Intensive outpatient level: IOP is a structured mental health or substance use disorder program combining individual, group, and family therapy.

Commercial and Medicaid IOP services do not require prior authorization under the stated policy provisions; Family Health Center behavioral health IOP is also covered without prior authorization or clinical review.

Crisis Intervention Level-of-Care Criteria

Crisis intervention is appropriate when the member is experiencing a mental health crisis requiring immediate evaluation and care.

Crisis level: Crisis intervention provides immediate evaluation and mental health care to a person experiencing a mental health crisis and is available through designated mental health programs 24 hours per day, 7 days per week.24 hours per day, 7 days per week

Commercial crisis intervention does not require prior authorization or clinical review; Medicaid crisis intervention is covered by fee-for-service Medicaid under the HMO Contract.

Intensive Outpatient Program Modality Criteria

IOP includes all of the following treatment components.

IOP consists of structured individual, group, and family therapy for a mental health or substance use disorder.

The policy states that prior authorization is not required for commercial and Medicaid IOP services under the applicable provisions.

Community Support Program Modality Criteria

CSP includes all of the following coordinated community-based services.

Community support: CSP provides coordinated treatment, rehabilitation, and support services through an identified program and staff to ensure ongoing therapeutic involvement and individualized services for persons with chronic mental illness in the community.

Commercial CSP does not require prior authorization or clinical review; Medicaid CSP is covered by fee-for-service Medicaid under the HMO Contract.

Crisis Intervention Modality Criteria

Crisis intervention includes all of the following immediate-response services.

Crisis intervention provides immediate evaluation and mental health care for a person experiencing a mental health crisis.24 hours per day, 7 days per week

Services may be provided through county mental health outpatient, inpatient, or day treatment programs and are available 24 hours per day, 7 days per week.