Priority Health obligations under Medicare

These are federal requirements for providers of Medicare Advantage and Medicare Prescription Drug plans.

Centers for Medicare and Medicaid (CMS) performance requirements

Priority Health is required to:

• Disclose all information necessary to administer and evaluate its Priority Health Medicare-branded products
• Establish and facilitate a process for current and prospective members to exercise choice in obtaining Medicare service
• Assure submission of medical records are complete and truthful
• Disclose quality and performance indicators for plan benefits for: Disenrollment rates for beneficiaries enrolled in the plan for the previous two years
• Member satisfaction

These are required under federal law per 42 CFR 422.64 and 422.504.

Non-discrimination

Priority Health does not discriminate against any health care professional that is acting within the scope of his/her license.

End-stage renal disease patients

Priority Health Medicare plans will not enroll an individual who has been medically determined to have end-stage renal disease, unless certain criteria are met. However, a member who develops end-stage renal disease while enrolled in Priority Health Medicare will not be disenrolled for that reason.

Cultural/linguistic non-discrimination

Priority Health is committed to ensuring that services are provided in a culturally competent manner to all members, including those with limited English proficiency or reading skills. The plan will perform annual surveys of linguistic services in provider offices and assist those offices in facilitating the use of language services, when necessary, to ensure that the communication needs of members are met.

If you need help assisting members with these services, call our Behavioral Health Department.

Credentialing and performance review

Priority Health maintains a comprehensive credentialing and re-credentialing process, as well as an ongoing program to review the performance of providers in its network. As part of this program, Priority Health provides:

• Written notice of material changes in participation rules;
• Written notice of decisions that are adverse to providers; and
• A process for appealing adverse participation procedures, including the right to present provider views on the decision.

If Priority Health terminates or suspends a provider contract, the plan will provide:

• Notice to the provider, including reasons for the action and the provider's right to appeal, the appeals process and timelines
• The composition of the panel hearing the appeal, a majority of whom will be provider peers
• Notice to any licensing or disciplinary bodies
• Timeframes (sixty (60) days written notice before terminating contract without cause)

The Office of the Inspector General (OIG) maintains a sanction list that identifies those individuals found guilty of fraudulent billing, misrepresentation of credentials, etc.

• Priority Health will pay sanctioned or excluded providers only for emergency services.
• Priority Health will review the sanction list with each new issuance at the OIG website.

Priority Health also maintains active programs and committees that involve providers in the areas of clinical management, utilization review, practice guidelines, quality of care and other areas.

Medical management and clinical guidelines

Priority Health internal policies and procedures are developed using current medical literature and are approved by physicians in conjunction with the Priority Health Medical Affairs Committee, Quality Integration Committee, Behavioral Health, Pharmacy and Credentialing Committees along with National Committee for Quality Assurance (NCQA).

Clinical Practice Guidelines can be found on this website in the Clinical Resources section.