Urgent after-hours prior authorization requests
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 auth needed in ER 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 can use our Auth Request tool to notify us of urgent/emergent admissions, deliveries and continuing stays through Clear Coverage™. Go to Auth Request.
Facilities have 24 hours or the next business day to notify the health plan of an urgent/emergent admission event. Use the Auth Request online automated authorization system to make your request through Clear Coverage™.
Utilization Review staff review authorization requests with clinical documentation using InterQual® medical necessity criteria to issue a coverage decision.
Non-participating hospitals and participating hospitals unable to use the Auth Request tool can fax a medical prior authorization form.
Providers outside of Michigan that do not participate with Priority Health: The Cigna PPO* Network is our preferred network for out-of-state coverage. Authorization requests sent to Priority Health for members with Cigna PPO* Network coverage will not be processed. 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
Urgent/emergent auths available through eviCore
Call eviCore toll-free at 844.303.8456. They'll respond to after-hours requests within 24 hours for Medicare and Medicaid/Healthy Michigan Plan members and within 72 hours for commercial group and individual members.
- Musculoskeletal services and surgeries, including arthroscopies
- Spinal procedures and surgeries: Open, percutaneous and endoscopic
- 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 Jan. 1, Memorial Day, July 4, Labor Day, Thanksgiving and the Friday after, and Christmas day.
Other after-hours urgent/emergent authorizations
- For all urgent/emergent auth requests from non-participating providers
- For services not available using Auth Request (drug fills, transfers and other services requiring medical necessity review)
- For practitioner/vendor requests normally processed by Clear Coverage™
Call us at 800.269.1260. Leave a phone number and message. An on-call nurse care manager will return your call within 30 minutes.