Plan basics

Review your Evidence of Coverage for information about benefits, procedures and much more.

You’ll find information about how to make the most of your plan using in-network doctors. You can learn about getting primary care and specialty care, like behavioral health and hospital services. There’s information about getting care after normal offices hours, receiving emergency care and what to do when you’re out of our service area.

You’ll also find the benefits and services included and excluded from coverage, copayments and other charges, restrictions on services outside the network, how to submit claims and how we evaluate new technology for inclusion as a covered benefit.

Prescription drug updates

We regularly review new drugs to help make sure you’re receiving safe and effective care. If you take prescriptions, please review our Approved Drug List occasionally to note changes or updates. We also provide information about our prescription coverage and pharmacy management procedures.

Grievance (complaint) procedure

The Centers for Medicare and Medicaid Services (CMS) calls complaints about the service you get from Priority Health or from our doctors, hospitals, pharmacies, etc., “grievances.” We will try to resolve any complaint that you might have over the phone. If you ask for a written answer to your phone complaint, we will answer you in writing. You can also send us your grievance in writing to:

Priority Health Medicare Member Resolution Coordinator
1231 East Beltline NE, MS 1150
Grand Rapids, MI 49525
or fax at 616.942.0995.

Quality performance

We want to make sure you receive safe and effective health care services. You can review summary information regarding our Quality Improvement Program performance and quality online.

Care management programs

We have professional care managers available to help our members coordinate their care. This is available to members who are at risk for, or who have experienced, a significant health episode or who have one or more chronic conditions. Learn what programs are available to help you manage chronic illnesses, how to use the services and how to become eligible.

Rights and responsibilities

As a Priority Health member, you have certain rights and protections afforded to you. You also have responsibilities. It’s important for you to understand these for your own protection and to make the most of your plan benefits. This is available in individual Medicare Advantage plans’ Evidence of Coverage document in Chapter 8.

Decision criteria

Our goal is to cover care that meets high medical standards and is also cost-effective. This is called utilization management. If you have questions regarding our process or decisions, contact Customer Service at 888.389.6648, seven days a week, 8 a.m. – 8 p.m. (TTY 711), and they’ll contact a health management staff member to help. Know that all utilization management decisions are based on appropriateness of care and service and that no financial incentives exist for issuing denials.

For more information visit Your relationship with Priority Health.