RE: Change to Prior Authorization Procedures for Select Services
IMPACTED PLANS: Medicaid, Child Health Plus, Essential Plan, HARP, HIV-SNP, Gold and GoldCare (All Medicare Advantage and Exchange Plans not applicable)
Dear MetroPlusHealth Provider,
As of July 15, 2026, the services below will change from requiring prior authorization to periodic retrospective review for medical necessity until further notice. MetroPlusHealth will no longer accept authorization requests for the services below. Claims for services rendered on or after 07/15/2026 will be processed without requiring authorization. Authorizations that are submitted after 07/15/2026 will not be processed.
MetroPlusHealth will conduct periodic retrospective reviews for medical necessity for these services starting 07/15/2026. These retrospective reviews may lead to a payment recoupment if the review determines services provided were not medically necessary.
| Type | Auth Requirement |
|---|---|
| Behavioral Health | Continuing Day Treatment |
| Behavioral Health | RTC Reintegration |
| Behavioral Health | Partial Hospitalization |
| Physical Health | Sleep Studies |
| Physical Health | Spinal MRI/CT* |
| Physical Health | Colonoscopies |
*For Spinal MRIs, no prior authorization will be required for up to two per year
If you have any questions regarding this notice, please contact MetroPlusHealth at: 800.303.9626, or email Provider Relations at [email protected].