Authorizations

• 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: 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

• Emergent inpatient authorization form A request is considered emergent if delaying treatment would put the patient's life in serious danger, interfere with full recovery or delay treatment for severe pain. Do not use this form for elective/planned inpatient admissions, instead use the Medical Authorization Form. If we determine your request does not meet the definition of an emergent authorization it will be processed according to standard timelines.
  All emergent cases are reviewed in 72 hrs or less.
• NICU/Sick newborn prior authorization form
• Acute Rehab/LTACH/SNF/SAR prior authorization/review form
  Use this form for all post-acute facility requests. Note: We've updated this form. Effective May 22, 2022, we will only accept this new form. Old forms will be returned via fax as they don't have all the necessary information.
• Bone marrow/peripheral stem cell or other blood cell transplant
• Solid organ transplant

Behavioral health authorization forms

• Behavioral health authorization form - Use this form for: psychiatric inpatient, outpatient psychotherapy (mental health and substance abuse), detoxification, residential treatment and other behavioral health services.
• Applied Behavioral Analysis (ABA) therapy authorization request form
• Transcranial Magnetic Stimulation (TMS) for depression authorization request

Home health care services forms

• Home health care services prior authorization form
• Home health care IV infusion services prior authorization form

Other medical authorization forms

• Clinical trials prior authorization form
• DME/P&O prior authorization form
• Medical prior authorization form