Service and device auth request forms
General authorization form
Medical prior authorization form - Updated 12/2017
For Medicare members: Use this form to request a pre-service organization determination when a Priority Health Medicare Advantage member is seeking services that may not be covered.
Notice for Medicaid providers: In order to receive payment from any Medicaid program, new federal regulation requires that those providing services to a Medicaid beneficiary must enroll in CHAMPS (Community Health Automated Medicaid Processing System) to receive reimbursement effective March 1, 2018. For more information, go to: https://milogintp.michigan.gov or Contact the Medicaid Provider Helpline 1-800-292-2550.
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
- Breast and ovarian cancer screening by molecular testing (General genetic testing form) - Updated 05/2014
- Clinical trials prior authorization form - Updated 05/2015
See also the Advance care planning assessment form - Updated 12/2015
Must be completed and returned with the clinical trial authorization request for members with Stage IV cancer or other life-threatening condition.
- 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
- Sub-Acute Rehab (SAR) Prior Authorization form - Updated 03/2014
Behavioral health forms
- Applied Behavioral Analysis (ABA) Therapy Authorization Request form - 06/2017
- Autism Spectrum Disorder Treatment Authorization Request - 09/2014
- Behavioral Health Outpatient Prior Authorization Form - Updated 07/2016
- 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
- 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
- Subacute rehab (SAR)/LTAC prior authorization/review form - Updated 8/2016
Use this form for Subacute rehab (SAR)/LTAC admissions, reviews or discharges for all products.
- Acute rehab review form - Updated 2/2016
Use this form for Acute Rehab reviews and discharges.
- Bone marrow/peripheral stem cell or other blood cell transplant - Updated 2/2016
- Solid organ transplant - Updated 02/2015