Starting Dec. 3, 2018, inpatient urgent/emergent admissions review process change 

We're changing our utilization review process to reduce your administrative work and remove authorizations on many services. These changes align with industry standards and ensure members receive the right care, at the right place, at the right time. The changes are based on data-driven processes to ensure utilization review aligns with industry best practices, including

  • First day review of inpatient urgent/emergent authorizations for in-network facilities, across all lines of business
  • Establishing local rules for observation authorizations for in-network facilities, across all lines of business

What diagnoses are included in the local rules?

View the local rules developed for authorization for observation vs inpatient admission for contracted hospitals.

Plan types affected

Authorization for inpatient admission will be required for all Priority Health product lines, including commercial group and individual plans, Medicare and Medicaid.

Utilization management program

View our utilization management program criteria for how we evaluate medical necessity and appropriateness of care.

Observation services

View our observation services for details around billing.

How to submit a retroactive review

Current process remains unchanged – submit via fax for review.

Inpatient admission request

If you have questions on how to submit your inpatient admission authorization using our online tool, see request an authorization for full details.