Information available online
We like to remind you every year of the plan information and programs available to you. The listings below highlight these areas and direct you to more information available online.
Quality Improvement Program Visit the
Provider Manual. To review complete copies of our Quality Improvement Evaluation, Quality Improvement Program Description and Quality Improvement Work Plan, contact Bob VanEck at 616 464-8204 or at
bob.vaneck@priorityhealth.com.
Disease and case management services Priority Health’s free
Health Management programs for asthma, diabetes, cardiovascular disease, pregnancy and tobacco cessation are designed to assist your practice. The programs help to educate patients about their health conditions, risk factors, adherence to evidencebased treatment and developing a personal action plan.
Clinical practice guidelines Clinical practice guidelines are available to support evidence-based care for children and adults. Additional practice management tools and patient education are also listed with each guideline. For example, for Chlamydia, you have access to a Chlamydia Fact Sheet for patients and Chlamydia FAQs, to name a few. You can access them in our
Clinical Resources area. Print copies are available upon request. Contact your PAC directly or through the Provider Helpline at 800 942-4765.
Utilization management, decisions and InterQual criteria Visit the
Provider Manual. If you have questions about utilization management decisions, would like copies of the medical criteria used to make decisions or would like to discuss the decision-making process, call the Health Management department at 800 942-4765. The following physicians are available on staff at Priority Health to review and answer questions about utilization decisions:
John Fox, MD Associate VP, Medical Affairs
616 464-8454
john.fox@priorityhealth.com The following pharmacists are available on staff to review and answer any questions about pharmacy-related utilization decisions:
Jim Mezwicki, R.Ph. 616 464-8617
jim.mezwicki@priorityhealth.com Erica Clark, Pharm.D. 616 464-8690
erica.clark@priorityhealth.com For behavioral health criteria, visit priorityhealth.com/provider/manual/auths/bh. In addition, your agency or facility may request a copy of the Behavioral Health department’s Standards and Criteria for Utilization Management. Questions about behavioral health-related utilization decisions or a copy of the utilization management criteria can be requested by contacting our Behavioral Health case managers at 800 673-8073 daily 8:30 a.m. – 5:00 p.m. Monday through Friday. If you have a question regarding general or specific utilization management decisions or processes, please contact the Behavioral Health department. A case manager will assist you with your questions or refer you to a board certified psychiatrist. Priority Health makes every effort to make utilization decisions that are fair and consistent in order to serve the best interests of the member. That is why we:
- Will make utilization decisions based only on appropriateness of care and service, as well as existence of coverage.
- Will not compensate practitioners or other individuals conducting utilization review for denial of coverage or service.
- Will not offer financial incentives or rewards for utilization decision makers to encourage denial of coverage or service.
- Will decide on coverage of new technology after comprehensive research and review by the chief medical officer and physician committees.
Medical policies Access our
medical policies online. You can obtain a copy of the criteria used in making a specific determination upon request. In addition, a Priority Health medical director is available to discuss by telephone decisions based on medical necessity. Please contact the Health Management department for a copy of specific criteria, to discuss the Utilization Management process or a decision, or to discuss a case with the medical director. The Health Management staff can be reached at the Provider Helpline, 800 942-4765.
Fraud and abuse Visit the "
Physician Office Requirements" section for information on fraud and abuse.
Member rights and responsibilities Rights and responsibilities can be found online in the
member handbooks.
Office management and standards We're here to help your office operate as effectively as possible. The "
Office Management & Standards" section links you to information regarding medical record criteria, which will help you create and maintain a participating relationship with Priority Health.
Topics:
