Provider office responsibilities

Verify the member's eligibility.

• Request the Priority Health card at the time of service, or
• Check member eligibility online using the Member Inquiry tool
• If patient has no ID card because he/she is new to Priority Health, call the Provider Help Line to verify eligibility.
  
• For Medicaid patients, request the patient's State of Michigan Medicaid eligibility card.

Collect the member liability copayment or coinsurance, when applicable.

• If the member doesn't know his or her copayment, check using the online Member Inquiry tool.
• Do not collect the member's entire out-of-pocket or deductible in anticipation of future visits. You may only collect the amount that represents member liability for the current visit.
  

NOTE: Priority Health cannot give legal advice to practices regarding collections. We recommend that providers research legal concerns – HIPAA, the Anti-Kickback statute, and Medicare - in order to protect your practices.

• Medicare and Medicaid do not allow copayment waiver except in limited circumstances. Waiver of copayment raises issues under Medicare charge-based reimbursement. If a waiver is routine, the provider's fee schedule is called into question because it does not represent the provider's real charges. This puts the provider at risk of misstating its charges to Medicare.
• Under the Civil Monetary Penalties law, a provider can waive a copayment if three conditions are met:
1. The waiver is not part of an advertisement or solicitation.
2. It is not done routinely.
3. The waiver is offered after making a good-faith determination of the patient's financial needs or exhausting reasonable collection efforts.
• Under the Anti-Kickback statute, the copayment waiver is allowed only in limited situations because it will misstate the provider's actual charges. Under HIPAA it is a crime for anyone to falsify a material fact.  It can be argued that the provider is misstating their charges to the plan because they did not collect the copayment.

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.