Submit prior authorization when required

Prior authorization may be required for certain drugs, devices, services, and procedures; when required, providers must submit a request demonstrating that the drug, service, or procedure is medically necessary per the Priority Health Provider Manual.

• Submit prior authorization requests when indicated on the Provider Manual.
• Demonstrate medical necessity in the request documentation.

Use updated coding and request prior authorization for PIPAC

Prior authorization is required per plan policy where applicable and coding updates include PIPAC‑specific procedure codes; providers must use the updated procedure codes on authorization requests when submitting for PIPAC-related services.

• Use the policy's updated coding that includes PIPAC-relevant procedure codes on authorization requests.
• Ensure authorization requests reflect the revised policy scope that includes PIPAC.

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Provide documentation to demonstrate medical necessity with prior auth

Providers must submit prior authorization requests where required and demonstrate medical necessity; individual consideration for investigational treatments requires prior plan approval and review by a Priority Health medical director or clinical pharmacist.

• Include clinical rationale and supporting documentation to demonstrate medical necessity.
• Requests for investigational treatments require prior plan approval and will be reviewed by medical leadership.

Document clinical trial participation and benefits applicability

Services provided as part of a clinical trial are governed by the Plan's Clinical Trials policy and member benefits; documentation should reference trial enrollment and applicability of member benefits.

• Document clinical trial enrollment and indicate whether the Plan's Clinical Trials policy applies for the member.
• Follow the Plan's Clinical Trials policy for coverage determinations on trial-related services.

Obtain prior approval for experimental/investigational/unproven (E/I/U) treatments

Requests for experimental, investigational, or unproven treatments will be denied unless approved by a Priority Health medical director or clinical pharmacist; individual case review may allow coverage for investigational yet promising care with prior plan approval.

• Obtain prior plan approval for E/I/U treatments to avoid denial.
• Requests for exception require review and approval by medical leadership.

PIPAC is treated as experimental/investigational/unproven

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is designated experimental/investigational/unproven for all indications and requests for PIPAC billed as standard‑of‑care will be subject to denial.

• Do not bill PIPAC as standard‑of‑care without prior plan approval.
• Seek prior plan approval and medical director review if requesting coverage for PIPAC in an individual case.