When you need pre-approval

Your plan only covers services that are medically necessary according to our medical and behavioral health policies. We make these policies with input from doctors not employed by Priority Health and/or according to criteria developed by state, federal and private agencies.

Your plan does not cover (pay for) some types of health care services and supplies, for example, surgery to make your nose smaller, because you do not need them for your health. Your plan will pay for other services or items that you do need for your health, if your doctor gets approval from Priority Health before you get them.

The process of getting approval from us in advance is called prior authorization.

Examples of services and items that need prior authorization

Remember, you don't need prior authorization in a medical emergency or when you need urgent care–just get help!

This list changes throughout the year as new technology is available and standards of care change, but in general, you need prior authorization before you get:

  • Inpatient hospital or facility services. (You don't need prior authorization to stay in a hospital for a limited time after delivering a baby.)
  • Intensive outpatient treatment services for substance abuse
  • Outpatient services as outlined in your plan documents 
  • Referrals to out-of-network providers
  • Durable medical equipment (DME) charges for TENS units, devices over $500, and all rentals
  • Prosthetics and orthotics charges over $500 and all shoe inserts
  • Stimulators
  • High-tech radiology, including but not limited to PET, MRI and CT scans and nuclear cardiology studies
  • Select injectable drugs
  • Home health care, including home infusion services and intermittent skilled services
  • Supplemental feedings by tube or IV
  • Transplants and evaluations for transplants
  • Genetic testing
  • Clinical trials
  • Comprehensive pain and headache programs
  • Additional items outlined in your plan documents

The prior authorization process

  1. Your doctor sends us a request to cover surgery, a procedure or an item, explaining why you need it.
  2. Based on that information, we decide whether or not the surgery, procedure or item is medically necessary for you.
  • Urgent requests: If delaying treatment would put your life or health in danger or delay treatment for severe pain, we must answer the request for the service or item within 72 hours.
  • Non-urgent requests: In most cases, we approve, partially approve or deny requests within 15 days of when we receive your doctor's request. In some cases, we need more information or more time to make a decision.

If we deny the request

A denial means that Priority Health will not cover the service or item. We will send you and your health care providers a letter explaining why we denied the request. You and your providers will have to decide what to do. You can:

  1. Go forward with getting the service or item at your own expense, or
  2. Appeal our decision. Check your coverage documents for instructions.

Claims denied due to no prior approval

Unless your doctor asks for prior authorization, you won't know ahead of time if the services or supplies will be covered. If you get the services without our approval, we will review the claim after you receive the services and we may or may not pay it.

  • If we find that the care you received was medically/clinically necessary and provided by an in-network provider, the care will be covered.
  • If we find that the care you received was medically/clinically necessary and provided by an out-of-network provider, the care may only be covered if the necessary care was not available from an in-network provider.
  • If we find that the care you received was not medically/clinically necessary, the care will not be covered.

When we deny a claim for care you get from a provider not in your plan's network, you're liable for the full cost of the services.