Understanding prior authorizations
Depending on your plan type, there are some health-related services and procedures that require prior authorizations prior to that service being performed. Some examples are inpatient hospitalization services, durable medical equipment, testing and treatment, elective procedures, home health care services, high-tech radiology and transplants.
There are two steps in the prior authorization process:
- Your health care provider submits the request for pre-approval to Priority Health. In-network providers submit authorization through Guiding Care, our electronic authorization tool. Out-of-network providers submit authorizations via fax. Fax forms can be found in the provider manual.
- The request is reviewed by Priority Health's clinical team. For standard requests, a decision will be made within 14 days. If an expedited request is submitted, a decision will be rendered within 72 hours.
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 if the service is denied. If a member has any questions about their authorization, they can contact customer service.
Prior Auth FAQs
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 authorizations be viewed from my member account?
No, this information is not available in your member account.
Has my authorization been submitted?
Reach out to your provider or Priority Health Customer Service to check the status of your authorization.
Why is a prior authorization needed? I have insurance.
Authorization is needed to verify the medical necessity of a service. Certain services require a full review to verify that they are appropriate.
Why does prior authorization take so long?
Once your provider submits the request for pre-approval to Priority Health, it can take up to 14 days to be reviewed. Notice of approval or denial is sent to your health care provider. If you want to check on the status of your appeal, contact your health care provider or call the Customer Service contact number on the back of your Priority Health member ID card.
Why can't I submit the authorization on my own?
Priority Health needs all of the supporting clinical documentation from the provider, including validated codes that a member cannot provide.
What types of services require prior authorization?
Some examples are inpatient hospitalization services, durable medical equipment, testing and treatment, elective procedures, home health care services, high-tech radiology and transplants.
Before authorizing a consultation with a surgeon or a scheduled spine surgery, a consultation with a Spine Center of Excellence provider will be required. Learn more about Spine Centers of Excellence.
How do I know whether an authorization is needed for a service?
You can check your plan documents in your member account to see what services need prior authorization according to your plan.
Why was my authorization denied?
Authorizations are denied for not meeting medical necessity criteria or being an excluded service.
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.