Balance billing is the practice of billing the patient for the difference between what Priority Health pays for covered services and the "retail" price you charge uninsured patients for those services.
Priority Health does not allow participating providers to balance-bill patients for covered services. In your contract with us, it states that you shall not look to Priority Health members for payment for covered services:
[Provider] agrees not to bill, charge, collect a deposit from, seek compensation from, seek remuneration from, surcharge, or have any recourse against a Member or persons acting on behalf of a Member, except to the extent that the applicable Plan specifies a copayment, coinsurance or deductible as permitted under the Coordination of Benefits Act.
Balance billing rules under MedicareThe Medicare Managed Care Manual, Chapter 4, Section 170, states in part: Medicare Advantage members are responsible for paying only the plan-allowed cost-sharing (copayments or coinsurance) for covered services.
- Priority Health as the Medicare Advantage Organization (MAO), not the Medicare member, is obligated to pay limited balance billing amounts to non-par providers; see below.
- If a member inadvertently pays a bill which is Priority Health's responsibility, we must refund the amount to the enrollee.
Balance billing specifically prohibited for Medicare-Medicaid eligibles
You may not balance bill for services and supplies furnished to Qualified Medicare Beneficiaries (QMBs); for them, Medicaid is responsible for deductibles, coinsurance and copayment amounts for Medicare Part A and B covered services.
For more information see MLN Matters SE1128.
Note: QMBs are sometimes called "dual eligibles." They are entitled to Medicare Part A, eligible for Medicare Part B, have income below 100% of the Federal Poverty Level, and have been determined to be eligible for QMB status by the State Medicaid Office.
Surprise billing legislation
On Oct. 22, 2020, Governor Witmer signed two bills into law that prohibit providers from sending surprise bills to patients.
- Status claims
- Claims Inquiry tool guide
- Edits Checker tool guide
- Claim deadlines
- Set up electronic payments
- BH provider billing
- Facility billing
- Advanced practice professional billing
- Professional billing
More billing topics:
- ACA non-payment grace period
- Ambulatory surgery center billing
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies