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

Covered and non-covered services under your SNF contract

Always refer to your Priority Health contract to identify what services will be paid by Priority Health. This is particularly important as it will guide you in understanding if certain ancillary services are your responsibility.

Don't know what your contract covers? Contact your facility administrator for information. Your Priority Health Case Manager does not know the specifics of your contract.

Standard contracted services

All contracts include room, board, skilled services provided by the facility, and drugs. The Jimmo v Sebelius Settlement clarified CMS rules for skilled care and related documentation. See our Jimmo v Sebelius page for details and requirements for SNF education.

Ancillary services

These services which may or may not be covered under your contract. Check your contract to determine if you are responsible for covering ancillary services such as transportation, dialysis, DME, chemotherapy, etc. If your contract covers these ancillary services, you are not responsible for paying the provider.

If your contract does not cover these ancillary services, you are responsible for paying the service provider. If you get a bill, direct the provider to submit the claim for reimbursement to Priority Health.

Non-emergent transportation

See our Ambulance services page for details on how Medicare and MAPD plans cover non-emergent transportation.

Retrospective authorizations

If you provide a service that requires prior authorization to an MA/MAPD plan member without first getting authorization, you can't send us an authorization request after the fact. You must submit a Request for payment. See Retrospective authorizations for details.

Appealing coverage for non-covered skilled nursing care

Should the MA/MAPD plan member appeal the termination decision, KEPRO, the Quality Improvement Organization (QIO) for the state of Michigan, notifies Priority Health of the member's appeal. Priority Health - not the SNF - must then issue a CMS-10124 form, Detailed Explanation of Non-coverage (DENC).

No later than the close of business the day that it is notified of the member appeal, Priority Health must:

  1. Complete a CMS-10124 form, Detailed Explanation of Non-coverage (DENC), with specific and detailed information about why SNF services are ending.
  2. Send a copy of the form to the Michigan QIO, KEPRO. 
  3. Issue the DENC form to the plan member.
The DENC serves to inform the member of the reason for the coverage termination so he/she has an opportunity to present his/her views to the QIO.

A SNF may not appeal on behalf of a member unless the SNF is member's appointed representative; proof may be required by the QIO.

Required appeal information

Be sure to have designated weekend and evening staff responsible for completing required tasks for KEPRO.

Priority Health staff can assist you with questions for after-hours or weekend appeals. Call our on-call nurse at 800.259.1260.

The following information must be faxed to KEPRO:

  • History and physical
  • Physician orders
  • Physician progress notes
  • PT evaluation and progress notes
  • OT evaluation and progress notes
  • ST evaluation and progress notes
  • Social service/DC planning notes
  • Skilled nursing notes
  • Wound care orders and flowsheets
  • Face sheet

Fax due dates and times:

  • During regular business week/hours: 5:00 p.m. on same day
  • After business hours: Noon the next day
  • Weekends: 3:00 p.m. Monday

Find more information on Medicare in-home safety assessments and post acute care

Obesity services forms

Physician-supervised weight loss program forms:

Obstructive sleep apnea device and study forms

Rehab facility forms

Transplant services forms