Medical criteria for authorizations

Priority Health uses the criteria below to help us determine medical necessity when we receive requests for services or equipment. In most cases, Priority Health staff perform InterQual® reviews independent from reviews submitted by providers.

Priority Health also recognizes that the criteria can never address all the issues; criteria cannot apply to every patient in every situation. Use of the criteria never replaces critical judgment.

Read our policy on establishing medical necessity criteria.

Commercial group and individual plan medical criteria

A copy of the criteria used in making a specific determination can be obtained by request. Call the Provider Helpline to reach the Health Management Department to:

  • Get a copy of specific criteria
  • Discuss the utilization management process or decisions

Go to our Utilization Management Program section to learn about:

  • InterQual® ISD criteria
  • InterQual® DME criteria
  • InterQual® Level of Care criteria
  • Priority Health Medical Policy Manual

InterQual® ISD, InterQual® DME and InterQual® Level of Care criteria are reviewed and approved annually by the Medical Director and Medical Affairs Committee.

eviCore healthcare guidelines are used to authorize genetic testing and advanced diagnostic imaging.

Medicaid and Healthy Michigan Plan medical criteria

For these members, Priority Health Choice®, Inc., follows:

  • InterQual® guidelines; see medical authorization criteria, above
  • State and Federal laws and guidelines regarding coverage and benefits

Priority Health has medical policies that address benefits that are specific to Medicaid and Healthy Michigan Plan members. The medical policies are reviewed annually or more frequently if necessary and approved by the Medical Affairs Committee.

Priority Health Medicare medical criteria

For Medicare Advantage plan members, Priority Health follows:

  • National and local coverage determinations
  • The Benefits Manual published by the Centers for Medicaid and Medicare (CMS) regarding coverage and benefits
  • InterQual®Level of Care criteria

    Note: CMS’s Two-Midnight Rule doesn’t apply to Priority Health members because our members have a Medicare Advantage (MA) plan. For observation to inpatient conversions, Priority Health only reviews at a higher level of care when continued stay episode days at the observation level of care are exhausted and the observation level of care criteria directs to a higher level of care.

If these publications require medical necessity to be met but do not specifically address criteria, Priority Health medical policies are used. They are reviewed and approved annually by the Medical Affairs Committee.

Learn more about Medicare coverage criteria in the Utilization Management Program section.