Authorizations

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.

How to request an authorization

Submit authorizations through our Auth Request tool. Turnaround times vary by plan requirements, but in all cases are 14 days or less.

Request an auth Check auth status

Out-of-network providers: see how to submit authorizations below.

Exceptions

Our Auth Request tool has two portals, GuidingCare and eviCore.

Here is what you can use each portal for.

GuidingCare eviCore
  • Post-acute facilities
  • Behavioral health
  • Durable medical equipment (DME)
  • Inpatient
  • Outpatient
  • Spine surgery
  • Joint surgery
  • Home health care
  • Planned surgeries and procedures
  • High-tech imaging
  • Lab and genetic services

eviCore resources 

 

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

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

Resources