Retrospective authorization requests

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.

• 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 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.