Information available online
Every year we like to remind you 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 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 with questions.
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 evidence-based treatment and developing a personal action plan. Get information on ways to use our services and see how we work with patients.
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. Print copies are available upon request through the Provider Helpline at 800 942-4765.
Utilization management, decisions and InterQual criteria
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 to review and answer questions about utilization decisions:
The following pharmacists are available on staff to review and answer any questions about pharmacy-related utilization decisions:
Review our behavioral health criteria
In addition, your agency or facility may request a copy of the Behavioral Health Department's Standards and Criteria for Utilization Management. You may ask questions about behavioral health-related utilization decisions or request a copy of the utilization management criteria by contacting our Behavioral Health case managers at 800 673-8073 from 8:30 a.m. to 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
View our medical policies. 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. You can reach the Health Management staff through the Provider Helpline, 800 942-4765.
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 "Provider responsibilities and standards" section of our online Provider Manual has information on everything from medical record documentation and confidentiality requirements to data exchange to provider status information.
Topics: Website news, Condition management, Utilization management
