Provider FAQs

Here you'll find answers to many of the questions that physicians and other providers ask us, divided by subject:
  
About Priority Health
About participating with Priority Health
About billing
About your patients

About Priority Health

Q: How many members does Priority Health service?
A: Almost 460,000.

Q: What geographical areas does Priority Health cover?
A: See our HMO service map for details on where our commercial health plans are offered in Michigan. In addition, we offer PriorityMedicare coverage in certain Michigan counties. Our national provider network allows us to offer a PPO plan to employers who have up to half their employees outside our service area.

Q: What products does Priority Health offer?
A:  We offer HMO, POS, and PPO plans in combination with Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs), flexible spending accounts, and HealthbyChoice^SM, our reward-for-performance health program. We also offer PriorityMedicare medical and prescription plans for individuals and for employer retiree groups, plus Medicaid and MIChild services and administrative services (ASO) for employers that fund their own health plans. See Our Health Plans for more information.

Q: What mailing address should I use to submit claims?
A: See the Provider Services Web page for our mailing addresses for regular claims and for Medicaid and MIChild claims.

About Participating with Priority Health

Q: How can I become a Priority Health provider?
A: Our Provider Network Development department will be happy to help you. E-mail us at provider.services@priorityhealth.com or call us at 616 942-4765 or 800 942-4765 and we'll get in touch with you.

Q: How can I access the website?
A: You can create your own secure online account here at www.priorityhealth.com by registering and creating a username and password. It takes about 48 hours (and sometimes longer) to verify your request for an account after you enter it.

With an online account, you can use our patient inquiry, claims, and other online tools to find patient and billing information and request prior authorizations. In addition, information about our formulary, clinical guidelines, "apple" ratings of PCPs, hospital safety and quality ratings, etc., are all available for anyone to access.

About Billing

Q: How can I bill electronically?
A: You can submit claims, referrals and authorizations, eligibility requests and responses, and payments/remittance advice forms directly to us in ANSI X12 4010A1 (HIPAA) file format. There are several transmission methods available. You can use our dial-up BBS (Bulletin Board Service) to send us information directly. Use FTP (file transfer protocol) to send and receive encrypted files over the internet. Or you can go through a clearinghouse with which you have a Trading Partner Agreement. You will need to use a clearinghouse if your computer system cannot generate a HIPAA-compliant claim. This is because Priority Health is required by HIPAA regulations not to accept any claim format and content that is not compliant with the regulations. Go to the Billing section of our online Provider Manual for set-up instructions for EDI (electronic data interchange).

Q: Can non-participating providers bill Priority Health electronically?
A: Yes. You simply need to have the correct set-up (see How can I bill electronically?, above).

Q: Who do I call when I have questions on electronic billing?
A: If your questions are about setup or transmission of EDI (electronic data interchange), contact our EDI department: 800 942-0954 or in Grand Rapids 616 464-8686, or e-mail EDISETUP@priorityhealth.com. If your question is about the details of a particular bill or payment, contact Provider Services.

Q: How do we correct an incorrectly billed claim?
A: Resubmit and rebill the entire corrected claim (with a refund, if applicable). If the diagnosis is what's being corrected, we'll also need you to attach a copy of the medical notes before we can change the diagnosis in our records.

Q: When we correct a claim, do we just rebill the item on the claim that was corrected?
A: No. Rebill the entire claim, adding a note that it is a corrected claim so we know it replaces the original claim.

Q: A claim was denied for "no authorization," but we have an authorization on file. What do we do?
A:  Please check the information you submitted. Claims will be denied if there were not enough units available on the authorization, if the dates of service authorized don't match the dates on the claim, or if the bill is for inpatient services but the authorization is for outpatient services, for example. You may want to submit a corrected claim, or ask for reconsideration; call Provider Services for help.

Q: What is the CBF listed on my statement, and how did it get there?
A: A CBF is a Credit Balance Forward. CBFs occur when Priority Health takes back more money than we are paying out, so a balance is due to us. To find the reason for the take-back, go to the previous Remittance Advice you received from us and it should show where the take-back occurred. Call the Provider Helpline for more information.

Q: We received a letter saying that our remit address is incorrect. How do we correct this?
A: The letter you received is generated automatically when the address we have on file for you does not match the address on your claim. If you have changed your address, even if it's simply from a street address to a Post Office box, we'll need to know the date that change was effective. We also may need a new W9 form.

About Your Patients

Q: What is my patient's deductible, and how much has been met?
A: To find out, call the Provider Helpline and select benefits & eligibility option. Or, e-mail us at customer.service@priorityhealth.com.

Q: Have you received injury details on my patient yet?
A: If we have sent a letter to our member asking for details on how, when and where his or her injuries occurred, we must hold all claims until the member replies. As soon as we receive that information we can begin processing your claims.