When you go to providers in your network, they let us know what you've paid and we process their claims automatically. You'll see your claims in your MyHealth account, and see how much you've paid toward your deductible and out-of-pocket maximum.
Claims for covered services
When you have a POS or PPO plan, you can go to in-network and out-of-network providers. (Just remember that some services require approval in advance from Priority Health before your plan will pay for them.)
Claims from in-network providers
Before you meet your deductible, the provider will send us the claim and then bill you for the full cost of the services you get. When you go to in-network providers, those costs are negotiated by Priority Health, so you'll usually pay less than you'll pay when you go to out-of-network providers.
After you meet your deductible, you'll pay copayments and/or coinsurance, as specified in your plan, and we pay the rest.
Claims from out-of-network providers
Before you meet your deductible, you'll pay the full cost of the services the provider charges.
After you meet your deductible, you'll pay higher "alternate" or "out-of-network" copayments and/or coinsurance, as specified in your plan. Priority Health will pay reasonable and customary amounts towards the providers' claims, but because there is no contract between Priority Health and the provider, the provider may bill you for the difference between what we pay and what they charge.
Asking for reimbursement if you paid a claim that your plan should pay
Sometimes a provider will ask you to pay in full. Maybe when they check your deductible online, what you've paid hasn't been posted to your electronic record yet, for example.
Ask us to reimburse you for the portion of the claim your plan should pay. Complete a Member Reimbursement Form and attaching proof of payment. A statement that shows only the amount you paid isn't enough, the proof of payment must show:
- What service(s) you received, including diagnosis and CPT codes
- Date of service(s)
- Place of service(s)
- Amount charged for the service(s)
- An indicator that the claim was paid in full
Send your request for reimbursement to:
Priority Health Claims Department
P.O. Box 232
Grand Rapids, MI 49501-0232
Send us your request within 60 days of the date you received the services. If you don't ask for reimbursement within 60 days, we can limit or refuse reimbursement. But we will not limit or refuse reimbursement if it is not reasonably possible for you to give us proof of payment in the required time, as long as you give us the required information as soon as reasonably possible.
We will only be liable for a claim or reimbursement request if we receive it within one year after the date of service, unless you didn't submit the claim because you are legally incapacitated.
Questions? Call our Claims department at 800.528.8762.
When a provider bills you for charges other than copayments, coinsurance, or any amounts Priority Health may pay towards your care, it's called "balance billing."
In-network providers aren't allowed to balance-bill you. They are under contract to accept the fees they negotiate with Priority Health.
Out-of-network providers may balance-bill you. We don't have contracts with them, so they can claim any amount they wish for your health care. This doesn't mean we will pay 100% of what they charge; we pay the maximum of what is reasonable and customary for the services you received based on the degree of skill required, the range of services provided by the facility where you went for the service, and regional variations in cost. After they receive our payment, they may bill you for the difference between the amount of their claim and what we paid.