Gastroenterology prior authorization at Priority Health
PA workflow, documentation criteria, and peer-to-peer prep — for prescribers and PA staff
Priority Health gastroenterology PA at a glance
Priority Health reviews gastroenterology PA submissions against its medical policy library, with rules drawn primarily from AGA / ACG / Cochrane IBD guidelines + STRIDE-II treat-to-target. Priority Health-specific context: Subsidiary of Corewell Health (Michigan integrated health system, formed from Beaumont + Spectrum 2022); ~1.3M members. Second-largest insurer in Michigan after BCBS Michigan. Michigan DIFS oversight.
Documentation packet — what to send
- IBD diagnosis confirmed by endoscopy/biopsy
- Disease distribution and severity
- Prior conventional therapies tried
- Steroid course (drug, dose, taper attempts)
- Therapeutic drug monitoring labs where applicable
- Tuberculosis + hepatitis B screening prior to biologic
Common denial patterns to pre-empt
Patterns observed in gastroenterology across payers, and where Priority Health's book of business overlaps:
- Step therapy through 5-ASA / immunomodulators / steroids first
- Switching between mechanism-of-action classes without documented failure
- Therapeutic drug monitoring not done before dose escalation
- Endoscopic disease not documented
- Step therapy on specialty drugs
- Medicare Advantage Part B drug step therapy
Appeal angles when Priority Health denies
- AGA / ACG guidelines for IBD positioning
- Endoscopic Mayo subscore or SES-CD documenting active disease
- Failure of prior biologic by mechanism of action (anti-TNF, anti-integrin, anti-IL-12/23, JAK)
- Steroid-dependence or steroid-refractory disease
Peer-to-peer prep
- Pull the most recent endoscopy report with photos if possible
- Quantify steroid dependence (mg of prednisone per year, taper attempts)
- Reference STRIDE-II treat-to-target if requesting mechanism switch
- Cite specific endoscopic scoring (Mayo, SES-CD) and the date
Drug-specific PA criteria at Priority Health
Deep dives on each drug's PA criteria at Priority Health:
Frequently asked questions
What documentation does Priority Health need for gastroenterology prior authorizations?
Priority Health's PA packet for gastroenterology typically includes: IBD diagnosis confirmed by endoscopy/biopsy; Disease distribution and severity; Prior conventional therapies tried; Steroid course (drug, dose, taper attempts). AGA / ACG / Cochrane IBD guidelines + STRIDE-II treat-to-target citations strengthen the submission.
What's the turnaround at Priority Health?
Priority Health standard decision: 30 days. Expedited (urgent care): 72 hours per 45 CFR §147.136. Internal appeal window if denied: 180 days.
Which gastroenterology drugs does Priority Health most often PA-restrict?
Top targets in gastroenterology: adalimumab, infliximab, ustekinumab, risankizumab, tofacitinib. Each follows the per-drug step therapy + documentation requirements published in Priority Health's medical policy library.
How do I prep a peer-to-peer with Priority Health in gastroenterology?
Pull the most recent endoscopy report with photos if possible Quantify steroid dependence (mg of prednisone per year, taper attempts) Have the policy URL and the patient's chart open before the call.
Generate a Gastroenterology PA packet
Open ApprovalHelp — generate a gastroenterology PA packet tailored to Priority Health's criteria, with prescriber attestation and supporting citations pre-filled.
Get started →Contact: hello@approvalhelp.com