Understanding prior authorizations
Some services require prior authorization before that service is provided or performed. Linked below is a list of all services currently requiring prior authorization. Requirements may vary by plan type.
Service types that commonly require prior authorization
- Admissions—all non-acute inpatient, partial and residential admissions, both medical and behavioral health
- Advanced imaging (i.e., CT, MRI, PET scans)
- Applied Behavioral Analysis (ABA)
- Bariatric services
- Cardiac diagnostic services
- Clinical trials
- Durable Medical Equipment (DME) and Prosthetics & Orthotics over $1,000 ($500 for Medicaid)
- Elective procedures done in a hospital inpatient or outpatient or ambulatory surgical center
- Gender dysphoria treatment and gender affirming surgery
- Genetic testing
- Home health
- Intensity-modulated radiation therapy (IMRT) and Radiation Therapy
- Pain and headache comprehensive programs
- Referrals to non-participating providers, if your plan doesn’t have an out-of-network benefit
- Sleep studies
- Supplemental Feedings given by tube or IV
- Transplants and evaluations for transplants
Note: All acute (emergency) inpatient medical or behavioral health admissions require review upon admission for authorization. A facility notifies Priority Health if you are admitted and submits clinical documentation for a level of care utilization review, similar to the prior authorization process.
The attached lists are for reference only and are not intended to be a substitute for benefit verification or Priority Health's medical policies. These lists are not exhaustive and are not necessarily covered under the member benefits coverage. Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s individual/group coverage, including, but not limited to, network requirements, exclusions and limitations, deductibles, copayments, and coinsurance applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
Prior authorizations FAQs
Why is a prior authorization needed?
Prior authorization is applied to certain services that may be experimental, not always medically necessary, or over utilized. The purpose of prior authorization is to make sure you receive services that are medically and clinical necessary, and that the services are appropriate for your condition or diagnosis.
What is the prior authorization process?
There are two parts to the prior authorization process:
- Your provider submits a request to Priority Health in the electronic authorization portal. The request includes the specific diagnosis and treatment codes for review, along with medical or clinical records to support the request.
- Priority Health reviews clinical documentation submitted with the request using appropriate coverage documents and/or criteria to make a decision. If the service is determined to be a covered benefit and medical necessity criteria is met, the request is approved. If not, the request is reviewed by a Medical Director for a decision. Your provider is notified of the decision in the electronic authorization portal.
Notice of approval is sent to all Medicare members, out-of-network members and those going through a reversed decision (a prior authorization that was previously denied). All members will receive a denial letter, with appeal rights, if the service is denied. If you have any questions about your authorization, contact customer service.
What criteria does Priority Health use for medical necessity reviews?
Priority Health uses written criteria to assist in the evaluation of medical necessity and appropriateness of care. This includes:
- Coverage documents—you can view your plan documents by logging into your member account
- Priority Health medical policies
- InterQual® clinical criteria—you can view this criteria by logging into your member account
- eviCore clinical criteria—you can view this criteria by logging into your member account
- National or Local Coverage Determinations (Medicare)—you can view this criteria at cms.gov/center/coverage.asp
Clinical criteria is intended for use by clinical professionals. If you have questions after looking at the criteria, reach out to your provider.
Can I submit a request for prior authorization on my own?
Your provider should submit a prior authorization request using the electronic authorization portal. Priority Health needs supporting clinical documentation from your provider for a medical necessity review, as well as diagnosis and procedure codes that you may not be able provide.
Has my authorization been submitted?
Reach out to your provider or Priority Health Customer Service to check the status of your authorization.
What's the status of my authorization?
You can check the status of your authorization by calling the Customer Service contact number on the back of your member ID card.
Can prior authorization status or decisions be viewed from my member account?
No, this information is not available in your member account.
How long does it take to get a prior authorization?
Once your provider submits the request for pre-approval to Priority Health, it takes less than14 days to be reviewed. Notice of approval or denial is sent to your health care provider through the electronic authorization portal. If you want to check on the status of your authorization, contact your health care provider or call the Customer Service contact number on the back of your Priority Health member ID card.
Why was my authorization denied?
When a prior authorization request does not meet medical necessity criteria, it is reviewed by a Medical Director and may be denied. A request may also be denied if it is a non-covered or excluded service. If the requested service is denied, your provider will be notified and you will receive a denial letter with the criteria used for review, reason for denial, and your appeal rights.
For any other questions about prior authorizations, send us a message in your member account or call the customer service contact number on the back of your member ID card.
To view your plan documents, log in to your member account and click My Plan.