Role & Responsibilities

Completion of the qualification form
This is a key requirement in order for members to maintain the Choice level of benefits. It typically requires a member to meet with his or her provider. However, if the member has been examined within six months of the effective date of coverage, and the required information (see below) is on file, a member can request that his or her provider completes and submits the form without a visit.

Providers may:

• Complete the paper qualification form your patient sends you,
  OR
  
• Download a paper HealthbyChoice Incentives qualification form (99KB PDF)
  OR
• Use the online HealthbyChoice Incentives tool to complete the required information.
  Note: If the required information is already in the Patient Profile, it will automatically populate the HealthbyChoice Incentives tool. Likewise, data entered in the HBCI tool will automatically populate Patient Profile.
  

Required information
Providers must note if their patients meet the criteria for three health indicators:

• Tobacco non-user
• Body Mass Index (BMI) less than 30
• Blood pressure less than 140/90

Reasonable alternatives

• In accordance with HIPAA guidelines for "reasonable alternatives," patients can maintain the Choice level of benefits by:

1. Completing a fasting cholesterol test
2. Completing a fasting blood sugar test
3. Agreeing to follow their provider's treatment plan

• It is the member's responsibility to make sure that any lab tests are completed within the first 90 days of benefit eligibility.  In these cases, providers should provide the alternative criteria information on the qualification form.
• If Priority Health does not receive proof via a claim that these tests were performed, the patient will be moved to the Standard benefit level.
• Providers are not required to outline or define the treatment plans they ask their patients to follow.