Out-of-network claims processing changes effective 2/1/17


Effective February 1, 2017, the way that out of network (OON) claims process is changing for:

  • Group PriorityPOS members
  • Group PriorityPPO members
  • Individual POS members

OON claims are now being processed by Data iSight, which is a tool that will use industry trends and area-specific data to determine the fair cost or usual and customary charge for an out of network service. Essentially, all claims for OON providers will now route to at a leased network rate or priced at usual and customary by Data iSight.

How if affects out-of-pocket costs

This will change what Priority Health reimburses for OON services, and therefore may change the out of pocket amounts some members pay. OON providers accept Priority Health payment as payment in full, but can bill the member the difference. Members are always encouraged to choose an in-network provider (which can be done via the Find a Doctor tool in MyHealth).