We require pre-authorization for certain services and procedures. In these cases, providers will submit clinical documentation and medical records demonstrating that the service or procedure is medically necessary.

Most authorization requests go through GuidingCare however, authorization requests submitted to Priority Health differ by provider and service type based on your contracting status. Learn more about the preferred submission methods based on your provider status below.

Authorization requests based on provider status

Based on your contracting status, authorization requests submitted to Priority Health differ by provider type. Please review and follow the procedures outlined below:

Contracted providers (in-network providers)

Contracted providers should request all authorizations through the auth request tool.

Guiding Care

As of Sept. 14, 2020 authorization requests for post-acute facilities, behavioral health and durable medical equipment (DME), inpatient, outpatient and home care can be submitted through our auth request tool.

Evicore

Authorizations including: All outpatient elective Radiology, Spine Surgery, Joint Surgery and Lab Services will require prior authorization from eviCore healthcare.

Effective September 5, 2018, certain high-tech imaging services will require medical review. You'll find online orientation, training materials and CPT lists for Musculoskeletal services, Advanced diagnostic imaging and Genetic testing at evicore.com/healthplan/priorityhealth.

Non-contracted providers (out-of-network providers)

All out of network providers must submit authorization through our provider authorization forms. 

Providers seeing Priority Health Medicare Advantage members with out-of-state coverage should submit authorization requests to Priority Health using our Medical Prior Authorization form.

All providers

Use the Medical Prior Authorization form to request a pre-service organization determination when a Priority Health Medicare Advantage member is seeking services that may not be covered.

Request an authorization

Services not included in the Auth Request tool:

  • Drug authorizations not related to an inpatient stay or home infusions - use the drug auth request forms
  • Medicare pre-service organization determinations.The Centers for Medicare and Medicaid Services (CMS) rules require that all Part C (Medicare Advantage) plans - NOT providers - give a specific written notice to members if a service or item isn't covered. The process for getting this written notice of non-coverage from Priority Health is called requesting a pre-service organization determination (PSOD). Go to PSOD instructions.
  • Services not covered by our plans 

Providers that can't use Auth Request tool:

Non-participating providers. See the authorization request forms.

Authorization quick reference list:

Most authorization requests go through GuidingCare unless otherwise specified.

The effective dates for these new prior authorization requirements will be communicated when finalized.

Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations; if there are none, our medical policy will apply.

When Priority Health is secondary to CMS or Original Medicare, we require prior authorization on obesity-related surgery, transplant services and home infusion services.

Click a letter to jump down to that section of the list:

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

Service Plans requiring prior auth Medical policy
A
Abdominoplasty/panniculectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91444
Abortion/termination of pregnancy Medicaid
Refer to the medical policy for coverage criteria		 91000
Acupuncture Not required
Generally not covered
May be covered with a rider or by some self-funded (SF) plans. See SF plan documents to confirm coverage
Adenotonsillectomy, pediatric (ages 0-17 only) HMO, POS, EPO, PPO, SF-POS, Medicaid InterQual
Allergy testing/immunotherapy Not required 91037
Ambulance services, air/fixed wing HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Ambulance services, emergent Not required
Ambulance services, non-emergent HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Apnea monitors and oxygen therapy, Medicaid patients under 21 only  Not required 91497
Artificial intervertebral discs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Authorized through eviCore healthcare
Augmentative communications/speech-generating devices Medicare, Medicaid 91499 applies only to Medicaid
Autism spectrum disorder treatment services, ages 0-18 only See policies for details 91615
91336
91318
Autologous chondrocyte implant/meniscal allograft/osteochondral HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

May not be covered by self-funded plans		 91443
Authorized through eviCore healthcare
B
Service Plans requiring prior auth Medical policy
BAHA device HMO, POS, EPO, SF-POS, Medicare, Medicaid 91544
Balloon sinus ostial dilation Not required 91596
Behavioral health therapies, initial evaluation Medicaid Submit Outpatient Services Request form to Priority Health
Behavioral health therapies, outpatient Not required
Behavioral health & substance abuse therapies, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare Submit Inpatient Services Request form to Priority Health
Biofeedback Not required 91002
Blepharoptosis/brow ptosis repair EPO, PPO, SF-POS, Medicaid 91535
Blood pressure monitors & ambulatory blood pressure monitoring (24 hour) Not required 91503
Bone density studies Not required 91494
Bone density studies, CT HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91494
Authorized through eviCore healthcare
Bone marrow/stem cell transplantation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91066
Breast MRI HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91545
Authorized through eviCore healthcare
Breast reconstruction & revision procedures not billed with qualifying diagnosis HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91545
Breast specific gamma imaging (BSGI) Not required
See policy for diagnosis limitations		 91568
Bronchial thermoplasty HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91577
C
Service Plans requiring prior auth Medical policy
Capsule endoscopy Not required
Payable for limited diagnoses, see medical policy		 91476
Cardiac/pulmonary rehabilitation (visit limits apply) Not required except by some employer groups 91318
Cardiovascular risk markers Not required 91559
Cardioverter defibrillators (ICDs) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91410
InterQual
Carotid artery stenting Not required 91495
Catheter ablation for cardiac arrhythmias HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91314
InterQual
Chelation therapy Not required
Payable for limited diagnoses, see medical policy		 91077
Chemosensitivity assays See policy for requirements 91540
Most testing authorized by eviCore healthcare
Clinical trials HMO, POS, EPO, PPO
Medicaid: Not covered

Medical policy applies to MyPriority individual plans, fully funded commercial groups and non-grandfathered self-funded groups (verify clinical trial coverage with the individual plan document for self-funded products).

For grandfathered self-funded groups that may opt out of PPACA expanded clinical trials coverage, refer to the Clinical Trials for Cancer Care medical policy 91448, below.		 91606
Clinical trials for cancer care Applies only to grandfathered self-funded groups that opt out of PPACA expanded clinical trials coverage. Not covered by most self-funded plans (verify clinical trial coverage with the individual plan document). 91448
Cochlear implant HMO, POS, EPO, SF-POS, Medicare, Medicaid 91544
InterQual-Adult, Pediatric
Complications to non-covered care Not required 91086
Computed tomography scanning for lung cancer screening HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Authorized though eviCore healthcare
Contact lenses/eyeglasses Not required 91538
Continuous glucose monitoring HMO, POS, EPO, PPO, SF-POS, Medicare

PA required for Medicare effective 01/01/2018

Medicaid: Not covered		 91466
Continuous passive motion (CPM), after day 21

HMO, POS, EPO, PPO, SF-POS, Medicaid

Medicare: No prior auth required but service only covered for 21 days

 InterQual
CPAP & other equipment to treat sleep apnea (i.e. ASV, APAP, BiPAP, oral appliances) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

For participating providers only, prior authorization is waived for the first three months of use		 91333
InterQual
Cranial helmets HMO, POS, EPO, PPO, SF-POS, Medicaid

DME limits apply		 91504
InterQual
D
Service Plans requiring prior auth Medical policy
Dental anesthesia Medicaid
Dental extractions Not required, but covered in limited circumstances; see policy for details

Medicaid: Not covered		 91542
Dental services Medicare
Detoxification HMO, POS, EPO, PPO, SF-POS, Medicare

Medicaid: Not covered by the health plan; managed by CMH and paid for by Medicaid FFS		 91104
Submit auth request via fax to Priority Health
Developmental disorders, pervasive See policy for details 91318
Dialysis access, permanent  HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

PA required for Medicare effective 01/01/2018		 91526
Dialysis for end stage renal disease HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

PA required for Medicare effective 01/01/2018		 91526
Drug-eluting stents for ischemic heart disease  Not required 91580
Drug testing, in-network labs Not required 91611
Drug testing, out-of-network labs HMO, EPO

POS, PPO plans: Not required. All OON labs will be processed at the member's out-of-network benefit level.		 91611
Drugs, injectable HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Certain drugs require prior authorization from the pharmacy department. See the drug PA forms list.
Durable medical equipment (DME) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

PA required for purchases >$1000, Medicaid DME purchases >$500, all rentals		 91110
E
Service Plans requiring prior auth Medical policy
Eating disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91007
Echocardiography - transesophogeal, transthoracic, Doppler  Not required
            		 
Electroconvulsive therapy (ECT) Not required
Medicaid: Not covered by the health plan; managed by CMH and paid for by Medicaid FFS		 91554
Enclosed bed systems for Medicaid members Medicaid 91498
Endoscopic submucosal dissection (ESD) Not required 91617
Enteral nutrition therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278
Enuresis therapy Not required
Subject to DME limits
Medicaid: Not covered		 91418
Experimental/investigational/unproven care HMO, POS, EPO, PPO
Not covered by most self-funded plans (verify coverage with individual plan document)
Medicaid: Not covered		 91117
F
Facial scar revisions Not required 91535
Fecal DNA screening (Cologuard) Not required 91547
Fecal microbiota transplantation/fecal bacteriotherapy Not required 91603
Feeding disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91469
Fetal surgery HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Some procedures may not be covered for Medicare and Medicaid		 91120
Foot care Not required
Payable for limited diagnoses, see medical policy		 91121
Frenulectomy/frenectomy Not required
Age limitations apply		 91542
G
Service Plans requiring prior auth Medical policy
Gastroparesis testing Not required 91572
InterQual
Gastroparesis treatment (not testing) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91572
InterQual
Gender dysphoria, non-surgical treatment  Required for certain pharmaceuticals. 91622 
Gender reassignment surgery All plans
Gender reassignment surgery may be covered when all plan and clinical criteria from the medical policy is met, as determined through authorization review.
 91612
Genetic counseling, testing & screening See policy for authorization requirements

Genetic counseling does not require prior auth		 91540
Authorized through eviCore healthcare
Genetic testing & screening, by out-of-network providers HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91540
Authorized through eviCore healthcare
H
Home health care: Home visits

Medicare, Medicaid required for all home health care visits - RN, PT, OT, ST, HHA, MSW*, RD*

*Medicaid: Not covered for MSW and RD visits

HMO, POS, EPO, PPO, SF-POS require prior authorization before the first visit

 91023
Home health care: Home infusion services, nursing care, palliative care, total parental nutrition HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91023
Hyperbaric oxygen therapy Not required
Payable for limited diagnoses, see medical policy		 91151
Hyperhidrosis, botox treatment and inpatient surgery only HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91451
I
Service Plans requiring prior auth Medical policy
Implantable heart failure monitors HMO, POS, EPO, PPO, SF-POS, Medicaid, Medicare 91610
Impotence and sexual dysfunction Not required 91160
InterQual
Incontinence supplies, Medicaid members Not required
See policy for limitations		 91502
Infertility and assisted reproduction See policy for coverage limitations 91163
Infusion services & equipment HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414
Submit auth request via fax to Priority Health
Inpatient care services: All admissions* including behavioral health and substance abuse HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

*Some elective procedures do not require health plan review (i.e. OB deliveries, colectomy, etc.), but do require an auth for claims payment. Other elective procedures require health plan review and specific criteria must be met (i.e. bariatric surgery, ventricular assist device, etc.).

Behavioral health and substance abuse inpatient services not covered for Medicaid.
INR monitoring or home prothrombin time Not required
Subject to DME limits
Medicaid: Not covered		 91507
Insulin pumps, ambulatory HMO, POS, EPO, PPO, SF-POS, Medicaid, Medicare*
*PA required for Medicare effective 01/01/18
Prior auth is required for both newly prescribed and replacement pumps		 91414
Intraoperative radiation therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91556
Intraperitoneal hyperthermic chemotherapy Not required 91548
Intracoronary brachytherapy Not required 91536
K
Knee arthroscopy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
 Authorized through eviCore healthcare
Kyphoplasty/vertebroplasty HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
 91581
Authorized through eviCore healthcare
L
Service Plans requiring prior auth Medical policy
Lumbar fusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
 91581
Authorized through eviCore healthcare
Lumbar laminectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
 91581
Authorized through eviCore healthcare
Lung volume reduction surgery Not required
Medicare: Only covered at certain facilities		 91472
M
Male gynecomastia PPO, EPO, SF-POS, Medicaid 91545
InterQual
Markers for digestive disorders HMO and EPO OON providers 91583
Submit auth via fax to Priority Health
Medical oncology (OP chemotherapy) Not required
  
Menorrhagia treatment/Mirena Not required 91575
Methadone maintenance Not required
Medicaid, Medicare: Not covered
Multi-marker tumor panels HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91609
Authorized through eviCore healthcare
N
Neuropsychological psychological testing Not required 91537
Non-acute inpatient services at skilled nursing, rehabilitation, and acute-care facilities HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91332
Submit auth via fax to Priority Health
Nutritional counseling Not required
Service Plans requiring prior auth Medical policy
O
Obesity-related services, medical management

Not required

Self-funded plans: May not be covered

 91594
Obesity-related services, surgical treatment HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Self-funded plans: May not be covered		 91595
Observation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Only required for non-participating facilities
Obstetric services/GYN care Medicaid
Only required for non-participating providers.
Call our Provider Locator Line to find in-network resources 		 
Oral surgery See policy 91542
Orthognathic surgery Medicaid 91273
InterQual
Orthopedic surgery (lumbar or cervical spine surgery, joint arthroscopy, hip, shoulder, knee replacement, shoulder repair) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
 Authorized through eviCore healthcare
Orthoptic and pleoptic training Medicaid requires prior auth for beneficiaries over age 21 91500
Orthotics: Shoe inserts, orthopedic shoes HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91420
InterQual
Orthotics/support device purchases, commercial/Medicare >$1000; Medicaid >$500 Medicare, Medicaid 91420
91339
InterQual
Oxygen therapy

Not required
P
Service Plans requiring prior auth Medical policy
Pacemakers, cardiac 

Not required

  
Pain management (injection procedures) 

Not required

  
Palliative care, inpatient or home HMO, POS, EPO, PPO, SF-POS 91558
Parenteral nutrition therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91517
Penile implants (organic origins only) Medicaid 91160
InterQual
Percutaneous left atrial appendage closure HMO, POS, EPO, PPO, SF-POS, Medicare 91605
Peroral endoscopic myotomy (POEM) Not required 91616
Pharmacogenomic testing See policy for authorization requirements 91540
Most testing authorized through eviCore healthcare
Port wine stains and vascular malformation Not required 91535
Power vehicles HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
InterQual
Prophylactic cancer risk-reduction surgery HMO, POS, EPO, PPO, SF-POS, Medicaid 91508
Prostatic artery embolization for benign prostatic hyperplasia (BPH)  Not required  91620
Prosthetics, purchase >$1000 for most plans; Medicaid >$500 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91306
Psychological evaluation and management of non-mental health disorders Not required 91546
Pulse oximetry for home use, after first three months of use HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91452
Pumps, implantable & external infusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414
Q
Quantitative electroencephalogram (QEEG) Not required 91510
R
Service Plans requiring prior auth Medical policy
Radiation oncology 

Not required

  
Radical prostatectomy  HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid InterQual 
Radiofrequency ablation for back pain, after two procedures HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Radiology: All non-emergent outpatient advanced diagnostic imaging services (MRA, MRI, CT, CTA, PET scans and nuclear cardiology) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

In-network: Authorized through eviCore healthcare

Out-of-network: Call eviCore

Details and exceptions: See Radiology services
Radiosurgery, stereotactic, and proton and neutron beam therapies HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91127
Reconstructive/cosmetic surgery HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91535
Reduction mammoplasty, male or female EPO, PPO, SF-POS, Medicaid 91545
InterQual
Rehabilitation therapies in the home (occupational, physical and speech)

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid require prior authorization before the first visit.
Coverage subject to visit limits

 91318
Rehabilitation/habilitative therapy (outpatient) Not required except by some employer groups
Coverage subject to visit limits		 91318
Renal artery stenosis Not required 91561
Rhinoplasty (with or without septoplasty) HMO, POS, EPO, PPO, SF-POS, Medicaid 91506
S
Service Plans requiring prior auth Medical policy
Sacroiliac joint fusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Septoplasty  Not required  91506
Skin conditions Not required, see policy for specifics 91456
Sleep studies, in-center, ages 18+ HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91333
Sleep studies, in-home Not required 91333
Skin substitutes Not required 91560
Speech therapy, outpatient Not required
Subject to visit limits
Medicare: PA required after therapy dollar cap is reached		 91336
Sterilization, Medicaid members Not required 91501
Stimulation therapy & devices: TENS only

 Not required for HMO, EPO, POS, PPO and Medicaid with specific diagnoses; see medical policy
Medicare: See InterQual		  91468
InterQual
Stimulation therapy & devices HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
See medical policy for criteria and authorization requirements.
See InterQual for Stereotactic Introduction, Subcortical Electrodes (Deep Brain Stimulation), Vagal Nerve Stimulators and for TENS (Medicare only)
 91468
InterQual
Substance abuse/behavioral health therapies, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare

Medicaid:  Not covered		 Submit auth request via fax to Priority Health
Substance abuse therapies, intensive outpatient

HMO, POS, EPO, PPO, SF-POS
Medicare, Medicaid: Not covered

 Submit auth request via fax to Priority Health
Substance abuse therapies, outpatient

Not required
Medicaid: Not covered

 Submit auth request via fax to Priority Health
Surgery, spinal  HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91531
Authorized through eviCore healthcare
Surgical treatment of sleep apnea Not required 91333 
T
Service Plans requiring prior auth Medical policy
Telemedicine Not required 91604
Temporomandibular joint disorders (TMD) Not required 91353
Titanium rib HMO, POS, EPO, PPO, SF-POS, Medicaid 91505
Thyroid-related procedures HMO, POS, EPO, PPO, SF-POS, Medicaid
Note: Medicare will require prior authorization effective 1/1/2019		 91621
Tonsillectomy, pediatric, ages 0-17 HMO, POS, EPO, PPO, SF-POS, Medicaid
 InterQual 
Transcatheter closure of septal defects Not required 91528
Transcatheter heart valves HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91597
InterQual is utilized for Transcatheter aortic valve replacement
Transcutaneous electrical acustimulation (TEAS) for hyperemesis Not required 91576
Transcranial magnetic stimulation therapy for depression HMO, POS, EPO, PPO, SF-POS, Medicare
 91563
Submit auth request via fax to Priority Health
Transplantation of solid organs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91272
Transurethral radiofrequency micro-remodeling for female incontinence Not required 91578
Treatment of gastroesophageal reflux disease (GERD) and Barrett's esophagus PA required for some services (i.e. Magnetic Sphincter Augmentation - LINX device).  See policy for coverage details. 91483
U
Service Plans requiring prior auth Medical policy
Umbilical cord blood testing & storage Not required 91459
Urolift/Prostatic urethral lift  Not required  91613
Uterine fibroid treatments  Not required 91573 
V
Varicose vein treatment Not required 91326
Ventilator, outpatient HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
Ventricular assist devices (VADs) and artificial hearts HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91509
Virtual colonoscopy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91547
Authorized through eviCore healthcare
Vision care/eye exams Not required 91538
Voice synthesizer Medicaid 91499