What health care providers need to know to work with Priority Health

Provider Manual

Authorizations

Requesting authorizations
Including urgent and retrospective auths
Drug auths
When meds require prior auth, including injectables
Auth reference list
Which services require prior auth
Durable medical equipment
When DME requires authorization
Retrospective auths
Requesting payment after the fact
Autism
Some services require prior auth
Emmi patient education
Some auths require education programs
Radiology auths
Requesting advanced diagnostic imaging studies
Behavioral health
Auths for BH services
Medical policies
Includes pending policy changes
Centers of Excellence
For treating back & neck pain
Billing and payment

How to bill
Professional and facility billing; diagnosis coding
Fee schedules
See our standard fee schedules
Procedures and services
Services from after-hours to vaccines
COB
Dual coverage, car accidents, Workers' Comp., Medicare
Medicare non-covered services
How to prevent claims from going to provider liability
Balance billing
You may not balance-bill a member for covered services.
Code modifiers
Guidance on the most confusing ones
Performance programs

Plans and benefits

HealthbyChoice plans
How to complete the 4 different plan forms
Provider responsibilities and standards

"CPT" (Current Procedure Terminology) is a registered trademark of the American Medical Association (U.S. Patent & Trademark Office Serial # 76379850). The CPT Coding Manual itself is also copyrighted (U.S. Copyright Office Serial # CSN0096041). As a result, we have included the following disclaimer on our medical policies:

All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical Association.

Last modified: 11/2/2015
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