Services that require prior approval

Priority Health must approve some services in advance before you receive them.  Here is a list of them.

This list may be updated during a Contract Year. See your Certificate of Coverage (COC) booklet for the prior approval process and how to check on your coverage before receiving services and supplies, or call Customer Service.

Services for which prior approval is required include, but are not limited to:

1. Consultations and procedures for:
    a. Bariatric (weight loss) surgery
    b. Physician supervised weight loss programs
    c. Parenteral/enteral feeding
    d. Cosmetic and reconstructive surgery
    e. Septoplasty
    f. Uvulopalatopharyngoplasty (UPPP)
    g. Orthognathic surgery (jaw reconstruction)
    h. Transplant and evaluations for transplant
    i. Comprehensive pain and headache programs
    j. General anesthesia for dental treatment for adults
    k. Male gynecomastia surgery
    l. Implantable cardioverter defibrillator
    m. PET scans and other high-technology radiology procedures
    n. Vision therapy
2. Inpatient care
    a. Elective admissions
    b. Inpatient skilled nursing, subacute, longterm acute and rehabilitation care
3. All behavioral health services
4. Referrals to Non-Participating providers, except for family planning services (Participating Providers are those listed in the Priority Health Provider Directory; a provider is Non-Participating if he or she is not listed in the Provider Directory)
5. Home health care
6. Hospice care
7. Home infusion services,
8. Durable medical equipment over $1000
9. Prosthetics and orthotics over $1000
10. Infusion pumps (implantable and external)

Priority Health may revise this list of services that require prior authorization at any time.