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 from in-network providers
When you receive services covered by your plan from an in-network provider, you will pay:
Before you meet your deductible: The full cost of the service negotiated by Priority Health with that provider
After you meet your deductible: Copayments and/or coinsurance, as specified in your plan
In-network providers send us claims letting us know the cost of the service and what you paid.
If you pay a claim in full when you've already met your deductible
Sometimes a provider will ask you to pay in full because what you have paid towards your deductible has not been posted to your electronic record yet.
Ask us to reimburse you by completing 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.
Claims for services from out-of-network providers
Other than for emergency and urgent care, you need pre-approval on any care you get from out-of-network providers before we'll pay for their claims. See When you need pre-approval for care for more details.
If you didn't get our approval before you got health care from an out-of-network provider, you will be responsible for 100% of the payment for that care. You can't submit the claim to us for payment. The amount you pay will not apply to your deductible, coinsurance maximum, or out-of-pocket limit.
When an out-of-network provider bills you for charges other than copayments, coinsurance, or any amounts Priority Health may pay towards your care, it's called "balance billing."
Because you're in an HMO plan:
- You normally will never go to an out-of-network provider. You have to get approval in advance (except for emergency care).
- If we approve you going to an out-of-network provider, we will only pay our "reasonable and customary" fees for any services you get.
- After we pay our normal fees, you may have to pay the balance that they charge.
In-network providers aren't allowed to bill you for the difference between the amount they have agreed to accept from Priority Health and the amount they normally charge others for the same service.