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: Providers outside of Michigan that do not participate with Priority Health: The Cigna PPO* Network is our preferred network for out-of-state coverage for commercial plan members. 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 or call Priority Health Cigna line at 833.300.3628. Providers seeing Priority Health Medicare Advantage members with out-of-state coverage should submit authorization requests to Priority Health using the Medical prior authorization form.

*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