Request elective retrospective authorizations through Clear Coverage™ starting Aug. 15
Effective Aug. 15, we're making it faster and easier to request elective retrospective authorizations using Clear Coverage™.
Retro authorizations are the latest enhancement to Clear Coverage™, a tool that's already made authorizations for many procedures and services faster and easier. You can:
- Use one process to request retro and prior authorizations for certain services
- Request elective retro authorizations online 24/7
- Backdate the date of service up to one year
- Get automatic approvals if the request meets Clear Coverage™ and InterQual (IQ) criteria
- Get faster approvals for retro authorizations that need additional review
- No need to communicate with Priority Health outside of the Clear Coverage™ tool
Soft launch June 15
Starting on June 15, you can start submitting retro authorizations through Clear Coverage™. Please don't duplicate requests by also faxing.
Plan types affected
Commercial and Medicaid: This new capability applies to services that can be requested today via Clear Coverage™
today for commercial and Medicaid.
Medicare: Only the following items can be requested retrospectively through Clear Coverage™.
- DME rentals, capped or short term, such as CPAP, wheelchairs, hospital beds, etc.
- Enteral formulas
Medicare does not allow for retro authorizations for others services, so requests will be canceled. Your next step is the appeal process.
When to fax instead
A reminder that non-participating providers can't use Clear Coverage™. They must fax auth requests to us.
To request a retro authorization request in Clear Coverage™, the member must have active coverage with Priority Health. If a member's coverage has termed, the request must be faxed.
Once the retro authorization is approved, you'll need to re-submit the claim for the services entered and approved.
If you submit the retro authorization via fax, you'll need to first check the Provider Center > Auth Inquiry tool to see if your request was approved. Then you can submit your claim.
The claim will need to be re-submitted as a new claim with the approved authorization number.
This rebilling process does not include Behavioral Health services.
Go to our Clear Coverage™ training resources page for a PDF of instructions with FAQs for more information.