Some services require prior authorization before that service is provided or performed. Linked below is a list of all services currently requiring prior authorization. Requirements may vary by plan type.
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Note: All acute (emergency) inpatient medical or behavioral health admissions require review upon admission for authorization. A facility notifies Priority Health if you are admitted and submits clinical documentation for a level of care utilization review, similar to the prior authorization process.
See a full list of services currently requiring prior authorization.
To search the list by code or keyword, click Ctrl + F on your computer's keyboard to open the search function.
The attached lists are for reference only and are not intended to be a substitute for benefit verification or Priority Health's medical policies. These lists are not exhaustive and are not necessarily covered under the member benefits coverage. Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s individual/group coverage, including, but not limited to, network requirements, exclusions and limitations, deductibles, copayments, and coinsurance applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
Prior authorization is applied to certain services that may be experimental, not always medically necessary, or over utilized. The purpose of prior authorization is to make sure you receive services that are medically and clinical necessary, and that the services are appropriate for your condition or diagnosis.
There are two parts to the prior authorization process:
Notice of approval is sent to all Medicare members, out-of-network members and those going through a reversed decision (a prior authorization that was previously denied). All members will receive a denial letter, with appeal rights, if the service is denied. If you have any questions about your authorization, contact customer service.
Priority Health uses written criteria to assist in the evaluation of medical necessity and appropriateness of care. This includes:
Clinical criteria is intended for use by clinical professionals. If you have questions after looking at the criteria, reach out to your provider.
Your provider should submit a prior authorization request using the electronic authorization portal. Priority Health needs supporting clinical documentation from your provider for a medical necessity review, as well as diagnosis and procedure codes that you may not be able provide.
Reach out to your provider or Priority Health Customer Service to check the status of your authorization.
You can check the status of your authorization by calling the Customer Service contact number on the back of your member ID card.
No, this information is not available in your member account.
Once your provider submits the request for pre-approval to Priority Health, it takes less than 14 days to be reviewed. Notice of approval or denial is sent to your health care provider through the electronic authorization portal. If you want to check on the status of your authorization, contact your health care provider or call the Customer Service contact number on the back of your Priority Health member ID card.
When a prior authorization request does not meet medical necessity criteria, it is reviewed by a Medical Director and may be denied. A request may also be denied if it is a non-covered or excluded service. If the requested service is denied, your provider will be notified and you will receive a denial letter with the criteria used for review, reason for denial, and your appeal rights.
For any other questions about prior authorizations, send us a message in your member account or call the customer service contact number on the back of your member ID card.
To view your plan documents, log in to your member account and click My Plan.