COB and authorizations

When Priority Health is a secondary payer

Original Medicare/CMS Medicare is primary

Bariatric surgery and infusion services require authorization. No auth is required for other services.

Commercial insurance (BCBS, Aetna, etc.) is primary

  • Bariatric surgery and home infusion services require prior authorization.
  • Most injectable drugs require prior authorization. Check the drug-specific listing.
  • Any service not covered by the primary plan but covered by Priority Health requires authorization by Priority Health. Example: sacroiliac surgery is not covered for most health plans. Priority Health covers it, but requires prior authorization.
  • Prior authorization is required for inpatient hospitalization when Priority Health is the secondary payer. This includes when the admission is urgent/emergent.

Note: Inpatient behavioral health services do not require prior authorization when Priority Health is secondary payer.

Medicaid/Healthy Michigan Plan (HMP)

When a member of Medicaid or Healthy Michigan Plan through Priority Health has other insurance, the other insurance is always primary. We won't require prior authorization for services the other plan covers, except for bariatric and home infusion services.

If a service is not covered by the primary payer but covered by the Medicaid/Healthy Michigan Plan through Priority Health, Priority Health may require prior authorization.

Note: Inpatient behavioral health and long-term psychotherapy are not covered.

Dual Priority Health plans

Follow the authorization rules for the primary plan.

OON servicing providers, eviCore-issued authorizations

Normally if the servicing provider is out-of-network (OON) and out of state, we will not load the servicing provider into our systems until a claim comes in. The exception is authorization requests that are authorized through eviCore healthcare.

  1. eviCore refers requesting providers to the Priority Health Provider Helpline if they can't find the servicing provider in our system.
  2. We'll send the servicing provider a Provider Change Form to complete and submit to us with their W-9.
  3. Our provider set-up team processes the request within 48 hours of receiving the information. Updated provider files are sent to eviCore daily.