Provider Office Responsibilities

Verify the member's eligibility.

• Request the Priority Health card at the time of service (print the Priority Health ID Card brochure, 550KB PDF), or
• Check member eligibility online using the Member Inquiry tool.
• For Medicaid patients, request the State of Michigan Medicaid eligibility card.

Collect office copayment or coinsurance, when applicable.

• If the member doesn't know his or her copayment, check using the online Member Inquiry tool.
  

Verify benefits by calling the Provider Help Line. Note: Benefits information is for your own use. Patients should call our Customer Service department for an explanation of their benefits (at the number on the back of their ID card). We will not be responsible for any information not quoted directly by Priority Health.

Help patients with referrals, and initiate prior authorization for drugs and services requiring it. For step-by-step instructions, go to the Authorizations section of this manual.

Complete claim forms (typed or electronic, no hand-written claims). For complete instructions go to the Billing & Payment section of this manual.

• For capitated services, submit claim forms within 45 days of the date of service.
• For billable services, submit claim forms within 90 days of the date of service.

Resolve discrepancies in claim processing within one year of the date of service.


Report suspected fraud and abuse. See the Priority Health Fraud & Abuse procedure.


Maintain medical records in compliance with state regulations.


Comply with the terms of the Priority Health contract.


Report all communicable diseases and other reportable health events to the appropriate entity as required by law.


Ensure that a professional is available to provide care to members a minimum of 20 hours per week.
See the Availability Standards section of this manual for more information.


Comply with state and federal regulations on patient rights, including informing patients of their right to formulate advance care directives.


Provide an interpreter for patients with limited English proficiency.

• Interpretation services must be offered at no cost to patients.
• This requirement applies to any entity receiving Federal financial assistance (including Medicaid and Medicare reimbursement).
• Contact the Provider Help Line if you need help finding a translator.