Urgent prior authorizations requests, including after-hours

A request is considered urgent if delaying treatment would:

• Put the patient's life in serious danger
• Interfere with full recovery
• Delay treatment for severe pain

No authorization needed in emergency room or observation setting

Services that generally require prior authorization, such as advanced diagnostic imaging, don't require prior authorization in an emergency room or observation setting.

Urgent / emergent hospital admissions

Participating hospitals must use our Auth Request tool to notify us of urgent / emergent admissions, deliveries and continuing stays through GuidingCare. Go to Auth Request (login required). 

Utilization Management team review authorization requests with clinical documentation using InterQual® medical necessity criteria to issue a coverage decision.

Non-participating hospitals can fax an emergent inpatient prior authorization form.

Providers outside of Michigan that don't participate with Priority Health: The Cigna PPO* Network is our preferred network for out-of-state coverage. Please refer to the members ID card for authorization instructions.

*The Cigna PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO Network for Shared Administration. 

Urgent / emergent Behavioral Health services

See the Behavioral Health section.

Authorization for hospital transfers

Urgent / emergent hospital transfers

If a member is experiencing a life-threatening condition and delay of transfer would jeopardize the health of the member, the receiving facility should submit a an authorization request after the transfer has occurred.

Non-urgent hospital transfers

When a member is receiving non-urgent inpatient care, prior authorization before the transfer has occurred will be required effective Mar. 10, 2025. If prior authorization isn’t approved before a non-urgent inpatient hospital transfer and our team later finds the transfer to be not medically necessary, we’ll cover the stay at the outpatient level of care. The receiving facility will be liable for the difference between the outpatient and inpatient level of care.

How to submit a hospital transfer request

Either the transferring or receiving facility should submit a new Acute / Emergent authorization request through GuidingCare and include the following information:

• Reason for the transfer
• Accepting attending physician name at the receiving facility
• Other facilities considered if the transfer is out-of-network for the member’s benefit
• Relevant clinical information
• Anticipated mode of transportation

The facility can ask for expedited review after submitting their authorization request in GuidingCare by calling:

• During business hours: Call our provider helpline at 800.942.4765.
• After business hours: Call our Utilization Management team directly at 800.269.1260.

Urgent / emergent authorizations available through EviCore

Call EviCore toll-free at 844.303.8456. They'll respond to after-hours requests within 24 hours for commercial group, individual and Medicaid/Healthy Michigan Plan members and within 72 hours for Medicare members.

• Genetic testing
• Advanced diagnostic imaging: CT/CTA, MRI, MRA, nuclear cardiac studies and PET scans

Their office hours are Monday through Friday, 7 a.m. to 7 p.m. Eastern Time. EviCore is closed on January 1, Memorial Day, July 4, Labor Day, Thanksgiving and the Friday after, and Christmas Day.

After-hours urgent / emergent authorizations

• Participating providers must use our Auth request tool (login required) for all authorization requests.
• Non-participating providers and facilities with urgent, after-hours authorization requests may call us at 800.269.1260. Leave a message along with a phone number, and our on-call nurse care manager will return your call within 30 minutes.