Stay in your PriorityHMO network
Your PriorityHMOSM plan has a network of health care providers - doctors, hospitals, pharmacies, labs and more - and when you go to them to get services covered by your plan, two things happen.
You save money
Priority Health negotiates the fees in-network providers charge. So, even when you're paying "full price" before you meet your deductible, you're getting a discount.
You save paperwork
In-network providers bill Priority Health automatically for covered services. You'll have no claims to file.
You need pre-approval to go out of network
To get non-emergency services covered by your HMO plan from out-of-network (also called "non-participating") providers, you need approval from Priority Health in advance, before you get the services. This is called "prior approval" or "prior authorization."
If the treatment recommended by your primary care provider (PCP) or specialist isn't available from your plan's network, your doctors can ask us for approval to refer you to an out-of-network provider.
Medical necessity is required for prior approvals
It's not enough that your doctor says you need the treatment from the out-of-network provider. The prior approval request has to show that the treatment is medically necessary for you.
If you get out-of-network treatment without approval
If your doctor doesn't ask for prior approval from us, or if we review your doctor's request and determine that the right, medically appropriate treatment IS available from providers in your plan network and we deny your request, then you'll be responsible for 100% of the payment if you get treatment from an out-of-network provider.
Exceptions to the pre-approval requirement
Covered dependent children living outside the service area: You don't need pre-approval from Priority Health to go to out-of-network providers if you're a dependent child covered by your parent's plan and living outside our service area.
Visits to "retail health clinics": You don't need pre-approval to go to a retail health clinic anywhere in the United States. A retail health clinic is a type of walk-in clinic located in retail stores, supermarkets and pharmacies that treat uncomplicated minor illnesses and provide preventive health care services.
Out-of-network providers may bill you even more
It's called "balance billing," where they'll charge you for the difference between their claim and what Priority Health will pay. Learn more.