Medical criteria for authorizations

Priority Health uses the criteria below to help us determine medical necessity when we receive requests for services or equipment. In most cases, Priority Health staff perform InterQual® reviews independent from reviews submitted by providers.

Priority Health also recognizes that the criteria can never address all the issues; criteria cannot apply to every patient in every situation. Use of the criteria never replaces critical judgment.

Read our policy on establishing medical necessity criteria.

Commercial group and individual plan medical criteria

Medical and clinical necessity is determined by using Priority Health’s medical and behavioral health policies or adopted criteria that have been approved by community physicians and other providers.

  • Priority Health medical policies are available here.
  • InterQual Clinical Criteria – to see criteria used to review elective procedures, durable medical equipment (DME), home health services, post-acute levels of care and behavioral health services, log into prism and use the Authorization Criteria Lookup under the Authorizations menu.
  • eviCore Clinical Criteria – to see criteria used to review high tech radiology and genetic testing requirements, log into prism and use the Authorization Criteria Lookup under the Authorizations menu.
  • Pharmacy prior authorization criteria are available here.

Medicaid and Healthy Michigan Plan medical criteria

For these members, Priority Health Choice®, Inc., follows:

  • InterQual® guidelines; see medical authorization criteria, above
  • State and Federal laws and guidelines regarding coverage and benefits

Priority Health has medical policies that address benefits that are specific to Medicaid and Healthy Michigan Plan members. The medical policies are reviewed annually or more frequently if necessary and approved by the Medical Affairs Committee.

Priority Health Medicare medical criteria

For Medicare Advantage plan members, Priority Health follows:

  • National and local coverage determinations
  • The Benefits Manual published by the Centers for Medicaid and Medicare (CMS) regarding coverage and benefits
  • InterQual®Level of Care criteria

If these publications require medical necessity to be met but do not specifically address criteria, Priority Health medical policies are used. They are reviewed and approved annually by the Medical Affairs Committee.

Learn more about Medicare coverage criteria in the Utilization Management Program section.