Balance billing for HMO plans

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.