When you can't submit a request for authorization before the supply or service is provided, you can submit a retrospective authorization request or a request for payment, depending on the patient's Priority Health plan. Example: Authorization for a wheelchair, for a hospital discharge over the weekend of a member who presented at 4 p.m. on a Friday.
For all plans except Priority Health Medicare
We accept retrospective authorization requests for services when necessary.
For drug and behavioral health auths:
- Use the drug authorization fax forms or the medical authorization fax forms.
- You must submit your request one year or less from the date of service.
- It takes up to 10 business days to complete retrospective requests.
For inpatient surgeries, DME and home care auths:
Use the medical authorization forms to request retrospective authorizations for services normally authorized by Clear Coverage™.
For advanced diagnostic imaging, musculoskeletal/spine services and surgeries, and genetic testing authorized through eviCore Healthcare:
- Don't use the Auth Request tool. Contact eviCore by phone at 844.303.8456.
- You must initiate your retrospective auth request within 120 calendar days from the date of service for commercial group or individual members, or within 30 calendar days of the date of service for Medicaid members.
- Normally, the services must have been urgent and medically necessary.
- Have all clinical information relevant to your request available when you contact eviCore healthcare.
For Priority Health Medicare Advantage patients
You may not request a retrospective authorization. Under Part C (Medicare Advantage) rules, once a service has been rendered without obtaining prior authorization it is considered to be post-service even if we have not received a claim. Post-service, you may submit a Request for Payment.
To submit request for payment:
No claim on file: Submit claim to
Priority Health, ATTN: Claims
P.O. Box 232
Grand Rapids, MI 49509
Claim submitted: We have made a decision if your claim was submitted. At this point you should follow the provider appeal process. See Reconsideration/appeals under Medicare for more information.
If we deny your request for payment, then:
The member has the right to appeal a denial. Note: A contracted provider cannot appeal on behalf of a Priority Health Medicare member. See Reconsideration/appeals under Medicare for more information.
Learn more details about Medicare non-coverage for Medicare Advantage patients.