When you need pre-approval for services
For some services covered by your plan, your doctor will need to get approval up front from Priority Health. This is called "prior authorization."
- If you or your doctor does not get Priority Health's prior authorization for a service that requires it, the service will not be covered 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 and/or covered.
Types of services that require pre-approval
This list is only a summary. Prior authorization requirements will vary depending on which Priority Health plan you have. Some plans don't cover maternity services or some mental health services, for example. Check your coverage documents to see what your plan covers.
- All inpatient hospitalization services
- Certain outpatient services
- Referrals to providers who don't participate in your particular Priority Health plan (check the Priority Health online Find a Doctor directory for participating doctors, hospitals, specialists, etc.); not applicable for PPO members
- Travel a significant distance from your home when you are more than 34 weeks pregnant
- Durable medical equipment purchases for more than $1,000.00, and all durable medical equipment rentals
- Purchases of prosthetics and orthotics for more than $1,000.00, and all rentals and all 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
- Selected injectable drugs in certain categories
- 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
The detailed list of services that need prior authorization is updated during the year as technology and standards of care change. It is available in our online manual for health care providers (warning: the language is very technical) or by calling our Customer Service Department.