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

• Advance care planning assessment form - Updated 12/2015
• Augmentative communication device - Medicaid only - Updated 01/2012
• Bilateral reduction mammoplasty - Updated 03/2015
• Bone Marrow/Peripheral Stem Cell or Other Blood Cell Transplant form - Updated 02/2016
• Breast and ovarian cancer screening by molecular testing (General genetic testing form) - Updated 05/2014
• Clinical trials prior authorization form - Updated 05/2015
• DME/P&O prior authorization form - Updated 04/2014
• Enteral nutrition therapy prior authorization form - Updated 6/2016
• General genetic testing - Updated 05/2014
  Use this form for retrospective genetic testing. Most genetic labs are managed through eviCore.
• Implantable Cardioverter Defibrillators (ICDs) with or without biventricular pacing - Updated 2/2016
  Priority Health commercial and Medicaid plan members must complete pre-surgical education for elective ICDs. Medicare patient completion is highly recommended. Register your patient using the link embedded in the prior authorization form and inform your patient of this requirement. See details.
• Next Generation Sequencing PA form
• Obstetrical Enrollment and Authorization Form Updated 04/2013
• Oxygen therapy and apnea monitors (Medicaid members under 21) - Updated 01/2012
• Percutaneous left atrial appendage closure (LAAC) - New 04/2016
• Solid Organ Transplant prior authorization form - Updated 11/2015

Behavioral health forms

Authorization forms

• Applied Behavioral Analysis (ABA) Therapy Authorization Request form - 01/2018
• Behavioral Health Outpatient Services Request Form - Updated 03/2018
• Behavioral Health Inpatient Authorization Form For pre-service, concurrent reviews, discharges, etc. - Updated 07/2016
• Transcranial Magnetic Stimulation (TMS) for Depression Authorization Request  - 03/2016

Other behavioral health forms

• Behavioral Health/Midlevel Practitioner Enrollment Form - 03/2015
  Required supplement to the CAHQ online application for behavioral health provider credentialing
• Coordination of Care with PCP form - 04/2013
  Use to provide information to the member's PCP and other specialists

Home health care services forms

• Home health care services PA form - Updated 11/2018
• Home health care IV infusion services PA form - Updated 08/2011
• Palliative care PA form - 10/2011
• TPN (Total Parenteral Nutrition) PA form - Updated 02/2015
• Telehealth services PA form - Updated 02/2015

Knee and spine procedure forms

• Sacroiliac (SI) joint fusion prior authorization form - 08/2014
• Spine referral for neurosurgeon or orthopedic surgeon evaluation PA form - Updated 08/2012

Obesity services forms

• Bariatric surgery - Updated 03/2015

Physician-supervised weight loss program forms:

• Intake form 
• Weight reduction plan 
• Monthly assessment form 
• Completion form 

Obstructive sleep apnea device and study forms

• In-center and in-center split night sleep studies PA form* - Updated 03/2015
• CPAP Titration, PAP NAP or MSLT PA form - Updated 03/2015
  Reflects changes to the Obstructive Sleep Apnea medical policy effective 02/26/15
• CPAP PA form (including BiPAP, DPAP, VPAP and AutoPAP) - Updated 03/2015
• STOP BANG questionnaire

Rehab facility forms

• Acute Rehab/LTAC/SNF/SAR prior authorization/review form- Updated 11/2018
  Use this form for Acute Rehab/LTAC/SNF/SAR admissions, reviews and discharges for all products

Transplant services forms

• Bone marrow/peripheral stem cell or other blood cell transplant - Updated 02/2016
• Solid organ transplant - Updated 02/2015