Service and device auth request forms

General authorization forms

Medical prior authorization form – Updated 03/2018

Out-of-network providers: Use this to request prior authorization for medical services if there is no service-specific form

Providers outside of Michigan that do not participate with Priority Health: The Cigna PPO* Network is our preferred network for out-of-state coverage. Authorization requests sent to Priority Health for members with Cigna PPO* Network coverage will not be processed. Please refer to the members ID card for authorization instructions. 

*The Cigna PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO Network for Shared Administration. 

In-network providers: Use this form only if the services are not available in Auth Request (Clear Coverage™ and eviCore).

All providers: Use to request a pre-service organization determination when a Priority Health Medicare Advantage member is seeking services that may not be covered.

Out-of-state HMO/EPO request form – New 10/2018

Note: Should only be used for out of state requests for HMO/EPO members who reside in Michigan and have Cigna on the back of their membership ID card.

Service- or device-specific forms

Behavioral health forms

Authorization forms

Other behavioral health forms

Home health care services forms

Obesity services forms

Physician-supervised weight loss program forms:

Obstructive sleep apnea device and study forms

Rehab facility forms

Transplant services forms