Medical Criteria for Authorizations

Priority Health uses the criteria below to assist in determining medical necessity when we receive requests for services or equipment. 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.

For more information
A copy of the criteria used in making a specific determination can be obtained by request. Contact the Health Management Department using the Provider Helpline to:

• Get a copy of specific criteria
• Discuss the utilization management process or decisions
• Discuss a case with the Priority Health Medical Director

Go to:
Medical criteria for PriorityMedicaid^SM and PriorityMedicare^SM programs

Go to the Utilization management section of this manual to learn about:
InterQual^® ISD Criteria
InterQual^® DME Criteria
InterQual^® Level of Care Criteria
Priority Health Medical Policy Manual

InterQual ISD, InterQual DME and InterQual Level of Care criteria are reviewed and approved annually by the Medical Director and Medical Affairs Committee.