Your responsibilities as a plan member

Your responsibilities as a member of a medical plan

You can find a complete list of your responsibilities as a Priority Health medical plan member in your coverage documents. You are responsible for:

• You must read the coverage documents that explain your health plan and the accompanying member materials, and comply with the requirements.
• You must call us with questions.
• Priority Health Medicare, PriorityHMO^SM, PriorityEPO^SM and PriorityPOS^SM members: You must coordinate all medical services through your primary care physician (PCP) or other primary health care provider, except in the case of a medical emergency.
• You must obtain prior approval from your PCP and Priority Health for some services, including all services from non-participating health care providers, and comply with the limits of any approval of services.
  • Services that require pre-approval or "prior authorization" are listed in your coverage documents, and also listed in this handbook, here.
  • "Participating providers" are health care providers that are contracted to accept your Priority Health plan. They are listed in the Find a Doctor online provider directory.
• You must receive a physical examination from your PCP within one year of joining Priority Health.
• We recommend you use participating health care providers for all services and supplies not requiring prior approval.
• You must contact participating health care providers to arrange for medical appointments, and notify them in a timely manner if an appointment must be canceled.
• You must pay copayments and deductibles at the time service is provided.
• You must present your ID card to the health care provider before you receive a service.
• You must participate in your health care as much as possible by working to understand your health problems.
• You must follow the treatment goals and other instructions given to you by your doctor or other health care provider. You may participate in developing your treatment goals when possible. Priority Health or your health care providers may ask you to enter into an explicit written agreement setting forth your treatment plan to ensure you understand the instructions.
• You must supply, to the extent possible, information needed by us and by health care professionals to provide proper care.
• You must notify health care providers and us if you have other health insurance coverage.
• You must provide truthful information on your application, your enrollment form and in any other information provided to us.
• You must promptly notify us of any change in address.
• You must promptly notify us if your ID card is stolen.
• You must cooperate with us to prevent the unauthorized use of your ID card and to prevent anyone from obtaining benefits in your place.
• You must treat health care providers and their staffs with respect.

Your responsibilities as a member of a wellness program

• Following the care advice offered by Priority Health
• Providing Priority Health with information necessary to carry out its services
• Notifying Priority Health and your doctor or other primary health care provider if you decide to disenroll from the program