Medicare AdvantagePrior AuthHigh impact
Retrospective authorizations limited effective Nov. 1
Priority Health·Provider News
Effective date
Nov 1, 2026
We identified it
Aug 18, 2026
Summary
Effective November 1, 2026, Priority Health will no longer accept retrospective prior authorization requests except in limited exception cases (emergent care, coverage identification issues, administrative errors, continuity of care, and post-procedure code changes). All prior authorizations must be obtained before services are rendered for medical/surgical, outpatient, lab, and drug services across all plan types. Claims submitted without prior authorization will be denied to provider liability without medical necessity review unless exception criteria apply.
Action Required
Before November 1, 2026: (1) Billing team must update all scheduling and pre-visit workflows to verify prior authorization requirements at time of scheduling—do not schedule services without confirming auth needs; (2) Front desk staff must confirm member eligibility at check-in and verify authorization is on file before service delivery; (3) Billing team must submit all prior authorization requests at least 7 days before the scheduled service date in the billing system; (4) Update billing software to flag claims for services requiring authorization that lack corresponding auth documentation and prevent claim submission; (5) Providers and clinical staff must be trained that retrospective authorization requests will only be accepted in documented exception cases—update encounter templates to capture exception documentation if applicable. CONSEQUENCES: Claims for authorized services rendered without prior authorization on file will be denied to provider liability (no member balance billing allowed) and will not be reviewed for medical necessity unless exception criteria are met. Claim denials cannot be appealed by contracted providers on behalf of Priority Health Medicare members; only the member may appeal.