Reminder: 7 days is the new standard authorization turnaround time

As a reminder, per Centers for Medicare and Medicaid Services (CMS) requirements, the turnaround time for standard authorization requests is now seven (7) days or less. This change went into effect Jan. 1, 2026. 

If a turnaround time of seven days or less is appropriate for your patient, please submit your authorization request as standard rather than expedited. Expedited requests should be reserved for cases requiring a response within 72 hours.

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Register now for our May 21 billing & coding webinar

Join us for a billing & coding webinar on Thursday, May 21 at noon for information on:

• Important reminders about submitting claim disputes
• Documenting and coding heart conditions, diabetes, and stroke for Risk Adjustment

How to register

You can join us by registering online. 

Can't join us?

All webinars are recorded and posted to our provider webinars page within a week of the event, so you can watch at your convenience. 

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Drug changes coming July 1 for commercial group and individual members

Each July, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial group and individual formulary to align with industry and regulatory changes and to ensure our members have access to safe and effective drugs. Beginning Jul. 1, 2026, the following changes will take effect:

Pharmacy drug changes

• Dexcom G6 Continuous Glucose Monitor (CGM) will be removed from the market by the manufacturer
• Formulary alternatives include: Dexcom G7 and Freestyle Libre CGM products

Medical drug changes

• Lunsumio^™will have Site of Service requirements added for commercial group and individual members new to treatment. Members already approved for Lunsumio will remain approved at their current treatment location for the duration of their authorization

SaveOn SP Program changes 

The following drugs will be added to the SaveOn SP Program drug list: CLICK HERE

We’re notifying members 

Impacted members will receive a letter advising them of these drug coverage changes and what steps they can take prior to Jul. 1, 2026. If an alternative medication is available, those options will be listed.

Brand to generic drug changes effective Apr. 21, 2026

The following brand to generic coverage changes are already in effect or will take effect Jul. 1, 2026, for commercial group and individual members. Because brand and generic drugs are interchangeable at pharmacies, no action is needed from providers or members.

• Farxiga^® (5mg, 10mg) removed from commercial group and individual formulary effective Apr. 21, 2026
• Generic, dapagliflozin, is covered at Tier 1 
• Xigduo^® (5/500mg, 5/1000mg, 10/500mg, 10/1000mg) removed from commercial group and individual formulary effective Apr. 21, 2026
• Generic, dapagliflozin/metformin hydrochloride, was added to formulary at Tier 1 effective Apr. 21, 2026
• Xigduo 2.5mg/1000 mg tablet will be removed from commercial group and individual formulary effective Jul. 1, 2026
• Generic, dapagliflozin/metformin 2.5mg/1000mg hydrochloride, will be added to formulary at Tier 1 effective Jul. 1, 2026

Want more information?

These changes will be reviewed at our July 1 Formulary Updates Provider Webinar.

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Notice of Admission required for inpatient admissions effective Aug. 1

Effective Aug. 1, 2026, we’ll require Notice of Admission (NOA) for hospital inpatient admissions* for all plan types (commercial, Medicaid and Medicare). NOA is separate from and in addition to authorization requirements.

*Note: NOA isn’t required for behavioral health admissions

What is NOA and why are we implementing it?

NOA is a notification to the health plan that a member has been admitted as an inpatient. It is not an authorization or approval, and it doesn’t change medical necessity requirements. It’s a notification that helps us manage eligibility, care, and downstream review more efficiently.

When is NOA required?

Facilities will be required to notify Priority Health within 24 hours of a hospital inpatient admission (or within one business day). 

How is NOA submitted?

The preferred NOA method with the least administrative burden is ADT sharing, which will automate releasing a notification to us when a member is admitted. ADT can be accomplished through Epic Payer Platform or MiHIN (see details below). 

We’ll also accept manual NOA submissions via a form in our provider portal when we transition to Epic. This option will be available to all providers, regardless of which EMR you use. We’ll provide instructions for this submission process as we get closer to go-live.

How can you establish ADT with Priority Health?

Epic Payer Platform (EPP)

For groups on Epic’s EMR, ADT sharing is available through EPP. Setup can take 2-3 weeks, after prerequisites (EPP and clinical data sharing implementation) are met. Contact Clyde Kinney, Priority Health Director of Provider Network Analytics (Clyde.Kinney@priorityhealth.com), to get started.

MiHIN

We can also accept NOA data via MiHIN. To establish a new feed with MiHIN, submit a MiHIN Helpdesk ticket either through their JIRA portal (preferred) or by emailing help@mihin.org.

Get more information in our FAQ

We’ve put together a comprehensive FAQ with additional information about the NOA and process. Access the FAQ online.