PA Form

Important Notice:

This is not an appeal. A peer-to-peer discussion offers an opportunity for providers to clarify clinical coverage criteria and understand the rationale behind a denial decision. It does not result in an overturn of a denial. If new or additional information is available regarding this request, please submit for reconsideration prior to initiating a peer-to-peer request by following: How to submit a drug coverage request - Priority Health

For Commercial, Individual, and Medicaid members, only the member or their authorized representative may initiate an appeal. To do so, they must contact Priority Health Customer Service at the number listed on the back of their insurance card and request an “appeal.” Contact number varies by plan type: Contact us | Priority Health
For Medicare members, an appeal must be formally submitted to overturn a denial decision. The process is outlined here: Medicare appeals | Priority

The Pharmacy Peer-to-Peer Review Process is available for authorization requests denied due to medical necessity, in accordance with NCQA Utilization Management standards. This process connects providers with a clinical pharmacist to discuss the denial rationale and clarify coverage criteria.

Note: Peer-to-peer reviews are not available for administrative denial reasons such as:

Non-covered services
Benefit exclusions
Member eligibility issues
Reimbursement concerns

For questions, contact the Priority Health Pharmacy Customer Service Department at 1-800-466-6642.

Submission Guidelines

After submitting the completed form, you may download a copy for your records.
Based on your responses in the Clinical Question section, a clinical pharmacist may contact the treating provider or representative at the callback number provided.
Two contact attempts will be made during the requested availability window.
Each medication is eligible for only one peer-to-peer discussion.

Appeal rights are included in every denial notification sent to both the member and the requesting provider. They are also available online at: Filing a complaint | Priority Health

Instructions

Fields marked with an asterisk (*) are required.
All requests are subject to review.

Patient Information

First Name

Last Name

Middle Name (optional)

Date of Birth Format: mm/dd/yyyy

Address (optional)

City

State

ZIP Code (optional) Format: 5 digits

Primary Insurance Name

Patient ID Number

Prescriber Information

NPI Number (individual)

First Name

Last Name

Specialty

Address

City

State

ZIP Code

Phone Number

Fax Number (in HIPAA-compliant area)

Medication/Medical and Dispensing Information

Medication Name

Dose Strength

Quantity

New Therapy

Renewal

Date Therapy Initiated (if renewal) Date format: mm/dd/yyyy

Call Availability

Provider Availability

Please provide at least three different call windows following these guidelines:

At least 24 hours (one business day) from submitting this form.
Date and Hours available:
Monday through Friday 8:00AM to 5:00PM Eastern Time Zone
Please provide preferences on a minimum of two separate weekdays
Requested date should be within 15 business days

Preference 1: Select Date/Start of 2 Hr Call Window:

Preference 2: Select Date/Start of 2 Hr Call Window:

Preference 3: Select Date/Start of 2 Hr Call Window:

Special Instructions

PA Request Number From Denial Letter (if available)

Attestation

I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, Insurer, Medical Group, or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.

Signature (enter name)

Signature Date Format: mm/dd/yyyy

Title of Requestor

Confidentiality Notice: The documents accompanying this submission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please arrange for the return or destruction of these documents immediately.

Prior Authorization Peer to Peer Form