Your responsibilities as a health plan member

Your responsibilities as a member of a medical plan

You can find a complete list of your responsibilities as a Priority Health medical plan member in your coverage documents. You are responsible for:

  • Reading the coverage documents that explain your health plan and the accompanying member materials.
  • Understanding and complying with the terms and conditions of your plan.
  • Calling us with questions.
  • Priority Health Medicare, PriorityHMOSM, PriorityEPOSM and PriorityPOSSM members: Coordinating all medical services through your primary care physician (PCP) or other primary health care provider, except in the case of a medical emergency.
  • Using participating health care providers for all services and supplies not requiring prior approval, or, if your plan allows you to use non-participating/out-of-network providers, then understanding the costs of services you choose to get from them. "Participating providers" are health care providers that are contracted to accept your Priority Health plan. They are listed in the Find a Doctor online provider directory.

    To use Find a Doctor:

    1. Log in or create a member account
    2. Select Find care in the top menu
    3. Click Find a doctor or specialist.
    4. Note that out-of-network PCPs or specialists must be authorized before a visit (called “prior authorization”). Your in-network PCP can help coordinate all referrals to specialists.

  • Getting prior approval for medical services when required by your plan and complying with the limits of any approval of services. Note: Services that generally require pre-approval or "prior authorization" are listed in your coverage documents, and also listed in this handbook, here.
  • Contacting participating health care providers to arrange for medical appointments, and notifying them in a timely manner if an appointment must be canceled.
  • Paying your copayments at the time service is provided.
  • Presenting your ID card to a health care provider before you receive a service.
  • Collaborating with your doctors and other health care providers to make informed decisions about the care you receive and to understand your health problems and health risks.
  • Following the instructions and working toward the treatment goals that you and your doctor or other health care provider agree upon. You may participate in developing your treatment goals when possible. Priority Health or your health care providers may ask you to agree to a written treatment plan to ensure you understand it.
  • Supplying your doctors and other health care providers and Priority Health with the information we need to make sure you receive proper care.
  • Notifying health care providers and us if you have other health insurance coverage.
  • Providing accurate information on your application or enrollment form and in any other information provided to us.
  • Notifying us of any change in address.
  • Notifying us if your ID card is stolen.
  • Cooperating with us to prevent the unauthorized use of your ID card and to prevent anyone from obtaining benefits in your place.
  • Treating health care providers and their staffs with respect.

Your responsibilities as a member of a wellness program

  • Following the care advice offered by Priority Health
  • Providing Priority Health with information necessary to carry out its services
  • Notifying Priority Health and your doctor or other primary health care provider if you decide to disenroll from the program