When you need pre-approval for services

For some services listed as benefits in your plan, your doctor will need to get approval up front from Priority Health. This is called "prior authorization" or "pre-approval." The process doesn’t take long – your doctor can request one online with us and often times have a decision instantly. But if your doctor doesn’t get pre-approval when one is necessary, the service will not be paid for by your health plan.

If your doctor requests a service from a health care provider who is not in our network, you and your doctor will get a letter from us indicating whether or not the service will be authorized/approved and/or paid for in part or in full.

Types of services that require pre-approval

This list is only a summary. Pre-approval requirements vary depending on which Priority Health plan you have. Check your plan documents to see what medical services are listed as benefits and which ones need pre-approval.

  • All inpatient hospitalization services
  • Certain outpatient services like tonsillectomies, prostatectomies and renal dialysis
  • Referrals to doctors who don't participate in your specific Priority Health plan (check the Priority Health Find a Doctor tool for participating doctors, hospitals and specialists, etc.)
  • Travel a significant distance from your home when you are more than 34 weeks pregnant
  • Purchases of more than $1,000 and all rentals of durable medical equipment (DME), and supplies for ongoing use of DME
  • Purchases of prosthetics and orthotics for more than $1,000, and all rentals and shoe inserts
  • Some behavioral health services, including applied behavior analysis (ABA), transcranial magnetic stimulation (TMS), partial hospitalization, and residential treatment for mental health or substance abuse
  • High-tech diagnostic radiology studies, including positron-emission tomography (PET) scans, magnetic resonance imaging (MRI), computed tomography (CT scans) and nuclear cardiology studies
  • Select injectable drugs
  • All home health care, including home infusion services and hospice care
  • Enteral and parenteral feedings
  • Certain stimulators
  • Experimental or investigational services
  • Transplants and evaluations for transplant
  • Genetic testing
  • Clinical trials for cancer care
  • Comprehensive pain and headache programs

Detailed list of services

See a detailed list of services that require pre-approval, based on your health plan: