COVID-19: Prior authorization information and updates

Prior authorizations are expected by our members and the employers who purchase our plans, to ensure the right care at the right time. Prior authorizations also help us understand and review utilization and meet the terms of our risk-based contracts.

We remain committed to serving you quickly by:

  • Processing all urgent inpatient admission and post-acute requests within 24 hours
  • Shortening the processing time for post-acute authorizations to help you discharge patients quickly
  • Never having required authorization for observation stays

COVID-19 testing

We do not require prior authorization for COVID-19 testing. Patients must work with their health care provider to get tested and cannot get testing without a provider's order for testing.

Supporting you with existing and new auth processes

Prior authorizations should be quick and easy. Even before this situation, we:

  • Processed urgent inpatient admissions and post-acute requests in 24 hours
  • Never required authorization for observation stays
  • Reviewed and auto-approved ICU and critical care cases
  • Worked seven days a week for quick turnaround

We've also made changes to remove barriers and facilitate access to patient care during COVID-19.

Facilities

  • You have 90 days to submit a retro authorization
  • We're processing authorization requests for inpatient and post-acute admissions within 24 hours
  • Intra-hospital transfers via ambulance to create bed capacity for COVID-19 treatment do not require authorization

Post-acute care

We have:

  • Never required a three-day inpatient stay before transfer to post-acute care
  • Shortened the processing time for post-acute authorizations to 24 hours to help discharge patients quickly

Elective procedures

We've extended prior authorizations through July 31, 2021 for elective procedures approved prior to the COVID-19 outbreak that were canceled or are pending rescheduling for members who have continuous enrollment in their plan at the time of service.

High-tech imaging, genetic testing and musculoskeletal services

In response to COVID-19, we've:

  • Removed all out-of-network rendering site restrictions for Medicare Advantage and Medicaid, effective Mar. 23, 2020
  • Moved all authorizations to a 180-day period, effective Mar. 26, 2020, dependent on continuous enrollment at time of service
  • Streamlined COVID-19-related high-tech imaging guidelines  

Pharmacy

For pharmacy prior authorizations set to expire through the end of June, we've extended the approval date by 90 days from the date it was set to expire. This does not include prior authorizations with intentionally short approval durations, such as short-term treatments.

This applies to commercial and Medicaid. Medicare authorization durations are through the end of the plan year, unless the approval is intentionally less than 12 months.

Frequently asked questions: prior authorizations

Has Priority Health changed its prior authorization requirements?

We still require prior authorizations, but have new and existing processes in place to better support you and your patients. These include:

  • Processing all urgent inpatient admission and post-acute requests within 24 hours
  • Shortening the processing time for post-acute authorizations to help you discharge patients quickly
  • Never having required authorization for observation stays

Does Priority Health require prior authorization for COVID-19 testing? 

No, we do not require prior authorization. Patients must work with their health care provider to get tested and cannot get testing without a provider’s order for the testing.

What if I had an approved authorization for an elective procedure and the procedure has been delayed? 

We're extending authorization expiration dates through the end of the year for elective procedures contingent upon continuous enrollment at the time of the service, procedure or needed equipment.

If I cancel elective surgeries, can I send my patients to out-of-network providers and facilities? 

CMS and the U.S. Surgeon General have both recommended that hospitals cancel elective procedures to ensure capacity for patients with COVID-19. We will not be authorizing out-of-network, non-emergent care for our members if their elective care is delayed.

Will Priority Health waive CMS's three-day hospitalization requirement prior to approving a transfer to a skilled nursing facility? 

Priority Health has never required a three-day inpatient stay before transferring patients to post-acute care. You can transfer your patients to post-acute care when appropriate. Remember that we require prior authorization for post-acute admissions.