We require prior 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.

Authorization requests based on provider status

Most authorization requests go through our Auth Request tool. 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:

Contracted providers (in-network providers)

Our Auth Request tool has two portals, GuidingCare and eviCore. In-network providers should submit all authorizations through our Auth Request tool with the exception of  NICU/sick newborn authorization form, Solid organ transplant authorization form, or Bone marrow/stem cell transplant authorization form. Turnaround times vary by plan requirements, but in all cases are 14 days or less.

GuidingCare

Our Auth Request tool will use GuidingCare to process your authorization requests for:

  • Post-acute facilities
  • Behavioral health
  • Durable medical equipment (DME)
  • Inpatient
  • Outpatient
  • Spine surgery
  • Joint surgery
  • Home health care
  • Planned surgeries and procedures

eviCore

Our Auth Request tool will use eviCore to process your authorization requests for:

  • High-tech imaging
  • Lab and genetic services
Request an authorization

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

Out-of-network providers: Use these forms to request prior authorization for medical services. Always use a specific service form when available. Turnaround times vary by plan requirements, but in all cases are 14 days or less.

Hospital and other facility forms

Behavioral health authorization forms

Home health care services forms

Other medical authorization forms

 

Services not included in the Auth Request tool:

  • Drug authorizations not related to an inpatient stay or home infusions - use the drug authorization 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