When you can't submit a request for authorization before the supply or service is provided, you can submit a retrospective authorization request or a request for payment, depending on the patient's Priority Health plan.
For participating providers (in-network)
Inpatient, LTACH, Acute Rehab, Skilled Nursing and Behavioral Health Facilities
A retrospective authorization review is an initial request that occurs after a patient has discharged from a medical facility. The review is used to determine medical necessity or coverage under a member’s health plan benefit.
Participating (in-network) medical and psychiatric inpatient hospitals, long-term acute care hospitals (LTACH), acute rehabilitation facilities, skilled nursing facilities (SNF), and mental health and substance use disorder residential facilities have up to 90 days past the date of admission to request retrospective authorizations for medical necessity determinations. After 90 days, the facility must submit a Level I provider appeal.
Prior authorization of admissions is required and should be requested before administering services. Retrospective review is allowed up to 90 days after admission when circumstances prevent prior authorization. This rule applies for all product lines including Commercial, Individual, Medicare and Medicaid plans.
Outpatient Services and Procedures, Durable Medical Equipment, Home Health Care
Non-Medicare outpatient services should adhere to a 90-day window for submission of retrospective authorizations. Retrospective authorizations submitted outside the 90-day window will be denied. After 90 days, the provider must submit a level 1 appeal.
For Priority Health Medicare Advantage patients
You may not request a retrospective authorization. Under Part C (Medicare Advantage) rules, once a service has been rendered without obtaining prior authorization it is considered to be post-service even if we have not received a claim. Post-service, you may submit a Request for Payment.
To submit request for payment:
Contracted providers can submit a payment request through the provider portal. Non- contracted providers can submit request to:
Priority Health, ATTN: Claims
P.O. Box 232
Grand Rapids, MI 49509
Claim submitted: We have made a decision if your claim was submitted. At this point you should follow the provider appeal process. See Reconsideration/appeals under Medicare for more information.
If we deny your request for payment, then:
The member has the right to appeal a denial. Note: A contracted provider cannot appeal on behalf of a Priority Health Medicare member. See Reconsideration/appeals under Medicare for more information.
Learn more details about Medicare non-coverage for Medicare Advantage patients.
For all plans except Priority Health Medicare
We accept retrospective authorization requests for services when necessary.
- Use the drug authorization fax forms
- You must submit your request one year or less from the date of service.
- It takes up to 10 business days to complete retrospective requests.
For advanced diagnostic imaging, lab and genetic testing are authorized through eviCore Healthcare:
- Don't use the Auth Request tool. Contact eviCore by phone at 844.303.8456.
- You must initiate your retrospective auth request within 120 calendar days from the date of service for commercial group or individual members, or within 30 calendar days of the date of service for Medicaid members.
- Have all clinical information relevant to your request available when you contact eviCore healthcare.