In-network vs. out-of-network
Stick with providers that are in our network
Your Priority Health plan has a network of health care providers - doctors, hospitals, pharmacies, labs and more - and when you go to them to receive health care services that are included in your plan, two things happen.
You save money
Priority Health negotiates the fees in-network providers charge. So, even when you're paying "full price" before you meet your deductible, you're getting a lower price.
You save paperwork
In-network providers bill Priority Health automatically for covered services. You'll have no claims to file.
What happens if you go out-of-network
You need pre-approval
To receive non-emergency services that are included in your plan from out-of-network (also called "non-participating") providers, you need approval from Priority Health in advance, before you get the services. This is called pre-approval or prior authorization.
If the procedure or treatment recommended by your doctor or specialist isn't available from your plan's network, your doctor can ask us for approval to refer you to an out-of-network provider.
Medical necessity is required for pre-approvals
It's not enough that your doctor says you need the treatment from the out-of-network provider. The prior approval request has to show that the treatment is medically necessary for you.
If you get out-of-network treatment without pre-approval
If your doctor doesn't ask for pre-approval from us, or if we review your doctor's request and determine that the right, medically appropriate treatment is available from providers in your plan network, we'll deny your request. That means you'll be responsible for 100% of the cost if you get treatment from an out-of-network provider.
Out-of-network providers may bill you even more
This is referred to as "balance billing," where an out-of-network provider will charge you for the difference in cost between their claim and what Priority Health will pay.