Priority Health Outpatient Physical Therapy prior authorization requirements (2026)
What Priority Health generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Commercial plans. Based on the cited policy, Priority Health does not generally require prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035). Confirm with Priority Health, as this can vary by plan.
Medical-necessity criteria Priority Health generally applies
Outpatient PT does not appear on Priority Health's published authorization quick-reference list for in-network providers (advanced imaging, radiation oncology, genetic testing, and sleep do). eviCore's Priority Health scope covers imaging/lab/cardiology/radiation oncology, not therapy visits. Treat as no-PA for in-network PT but VERIFY per member: benefit visit limits vary by plan, and plan- or employer-specific exceptions could not be publicly confirmed. Medical-necessity reviews generally, where they occur, use InterQual or plan medical policies.
Commonly required documentation
- No routine PA submission for in-network PT. Keep the referral/order where the plan requires one, evaluation, plan of care, and progress notes
- verify the member's visit limit before extended courses.
How to submit
- Method: Priority Health provider portal (GuidingCare) for services that do require auth
- Portal: Priority Health portal
Sources & verification
Sources: https://www.evicore.com/resources/healthplan/priority-health; https://www.priorityhealth.com/provider/manual/auths/in-network. Verified as ABSENT from the published PA list - an affirmative "never requires PA" could not be confirmed for every plan/employer. [NEEDS CLINICAL SPOT-CHECK] View the source policy. Last verified 2026-07-09.
Frequently asked questions
Does Priority Health require prior authorization for Outpatient Physical Therapy?
Based on the cited policy, Priority Health does not generally require prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035). Confirm with Priority Health, as this can vary by plan.
What does Priority Health require to approve Outpatient Physical Therapy?
Outpatient PT does not appear on Priority Health's published authorization quick-reference list for in-network providers (advanced imaging, radiation oncology, genetic testing, and sleep do). eviCore's Priority Health scope covers imaging/lab/cardiology/radiation oncology, not therapy visits. Treat as no-PA for in-network PT but VERIFY per member: benefit visit limits vary by plan, and plan- or em… Always confirm against the current Priority Health policy.
How long does a Priority Health prior authorization take?
Turnaround varies by plan and submission method. Check the Priority Health portal for current timeframes.
Submitting Outpatient Physical Therapy to Priority Health?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.