No auth needed

When performed by a participating provider in an outpatient setting, these services don't require a prior auth:

  • Colonoscopy 
  • Hernia repair   
  • Adenoidectomy 
  • Cystoscopy 
  • Lithotripsy 
  • D&C 
  • Myringotomy tubes 
  • Cholecystectomy

 

Service, surgery & device authorization forms

Request an authorization online

Participating providers may use our online Auth Request tool to request authorizations. Depending on the CPT code/procedure, you'll be taken to eviCore healthcare or to Clear Coverage™. In many cases, your authorization can be approved immediately. Learn more about using Auth Request, including types of procedures/admissions authorized, training materials, and more.

Request an auth


Request an authorization using form and fax

To request prior authorization for medical services both in and out of network, open the form, fill it in, save it for your records, then print and fax it to Priority Health.

The forms in this section are for provider use only.

General authorization form

Medical prior authorization form – Updated 10/2015
Out-of-network providers: Use this to request prior authorization for medical services
In-network providers: Use this form only if the services are not available in Clear Coverage™.
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.

Service- or device-specific forms

Jump down to:

Advance care planning assessment form - Updated 12/2015

Augmentative communication device - Medicaid only - Updated 01/2012

Bilateral reduction mammoplasty - Updated 03/2015
Complete online and save it for your records, then print and fax it to Priority Health.

Clinical trials prior authorization form  - Updated 05/2015
Complete online and save it for your records, then print and fax it to Priority Health.
See also 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
Complete online and save it for your records, then print and fax it to Priority Health.

Enteral nutrition therapy prior authorization form - Updated 6/2016
Complete online and save it for your records, then print and fax it to Priority Health.

General genetic testing - Updated 05/2014
Complete online and save it for your records, then print and fax it to Priority Health.
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
Complete online and save it for your records, then print and fax it to Priority Health.
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: Provider Manual > Authorizations >  Patient engagement

Intravenous Immunoglobulin (IVIG) PA form 

Next Generation Sequencing PA form 
Complete online and save it for your records, then print and fax it to Priority Health.

Obstetrical Enrollment and Authorization Form Updated 04/2013
Complete online and save it for your records, then print and fax it to Priority Health.

Oxygen therapy and apnea monitors (Medicaid members under 21)  - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.

Percutaneous left atrial appendage closure (LAAC)  - New 04/2016
Complete online and save it for your records, then print and fax it to Priority Health.

Behavioral health authorization forms

Home health care services forms

Knee and spine procedure forms

Obesity services forms

Obstructive sleep apnea device and study forms

Rehab facility forms

  • 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.
    Complete form online and save it for your records, then print and fax it to Priority Health.
  • Acute rehab review form  - Updated 2/2016
    Use this form for Acute Rehab reviews and discharges.
    Complete form online and save it for your records, then print and fax it to Priority Health.

Transplant services forms

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Last modified: 7/21/2017
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