Priority Health obligations under Medicare

These are federal requirements for providers of Medicare Advantage and Medicare Prescription Drug plans.

Centers for Medicare and Medicaid (CMS) performance requirements

Under the requirements of the Code of Federal Regulations Title 42 - Public Health (42 CFR 422), Priority Health is required to:

  • Safeguard patient privacy and maintain accurate and current records (422.118)
  • Disclose all information necessary to administer and evaluate its Priority Health Medicare-branded products (422.64 and 422.504)
  • Ensure "adequate" access to covered services and items, and provide for this in our agreements with providers, including 24 hour/7 day access (422.111)
  • Ensure medical record displays in a prominent place that the individual member has executed in an advance directive (422.128)
  • Establish and facilitate a process for current and prospective members to exercise choice in obtaining Medicare service (422.64 and 422.504)
  • Make good faith efforts to notify all affected members within 30 calendar days of a provider termination (422.111)
  • Assure submission of medical records are complete and truthful (422.310 and 422.504)
  • Ensure services are provided in a culturally competent manner (422.112)
  • Disclose quality and performance indicators for plan benefits for disenrollment rates for beneficiaries enrolled in the plan for the previous two years, member satisfaction, and health outcomes (part 504)
  • Adhere to CMS marketing provisions (422.80)
  • Adhere to CMS appeal and grievance procedures (422.562)
  • Prohibit the use of excluded providers (422.752)
  • Make good-faith efforts to notify all affected members of the termination of a provider contract 30 days before the termination by the plan or the provider (422.111)
  • Comply with the provisions of the Civil Rights Act, Age Discrimination Act, Rehabilitation Act of 1973, Americans with Disabilities Act, and the Genetic Information Nondiscrimination Act of 2008 (422.504)

Non-discrimination

Priority Health does not discriminate against any health care professional who is acting within the scope of his/her license.

We ensure that, in the delivery of health care services consistent with the benefits covered in their policies, members are not discriminated against based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

In enrollment, Priority Health does not discriminate based on claims experience, receipt of health care, medical history and medical conditions including physical and mental illness, genetic information, evidence of insurability, including conditions arising out of acts of domestic violence and disability.

End-stage renal disease patients

Priority Health does not enroll individuals who have been medically determined to have end-stage renal disease in our Medicare Advantage plans, except under certain situations described in Chapter 2 of the Medicare Managed Care Manual, "Enrollment and Disenrollment."

Cultural/linguistic competency

Priority Health is committed to ensuring that services are provided in a culturally competent manner to all members, including those with limited English proficiency or reading skills, as required by 42 CFR 422.112.

If you need help assisting members with these services, call the Provider Helpline.

Credentialing and performance review

Priority Health maintains a comprehensive credentialing and re-credentialing process, as well as an ongoing program to review the performance of providers in its network. As part of this program and as required under Chapter 6 of the Medicare Managed Care Manual, "Relationship with Providers", Priority Health provides:

  • Written notice of material changes in participation rules;
  • Written notice of decisions that are adverse to providers; and
  • A process for appealing adverse participation procedures, including the right to present provider views on the decision.

If Priority Health terminates or suspends a provider contract, the plan will provide:

  • Notice to the provider, including reasons for the action and the provider's right to appeal, the appeals process and timelines
  • The composition of the panel hearing the appeal, a majority of whom will be provider peers
  • Notice to any licensing or disciplinary bodies
  • Timeframes (60 days' written notice before terminating contract without cause, per 42 CFR 422.202)

Sanctioned providers

Each month CMS sends Priority Health the Medicare Exclusion Database (MED) of sanctioned providers. The MED is the "List of Excluded Individuals and Entities" maintained by the Office of the Inspector General (OIG). It identifies those individuals found guilty of fraudulent billing, misrepresentation of credentials, etc.

  • Priority Health will pay sanctioned or excluded providers only for emergency services.
  • Priority Health will review the sanction list with each new issuance at the OIG website.

Provider involvement in clinical programs

Priority Health also maintains active programs and committees that involve providers in the areas of clinical management, utilization review, practice guidelines, quality of care and other areas.

Medicare medical policy

Priority Health follows Medicare medical policy as found in National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). Priority Health follows WPS-Medicare LCDs for Part A/B Medicare and National Government Services (NGS) LCDs for DME. NOTE: Nine hospitals remain under NGS for Part A/B Services and for these hospitals only we follow NGS LCDs for hospital A/B services.

Medical management and clinical guidelines

Priority Health internal policies and procedures are developed using current medical literature and are approved by physicians in conjunction with the Priority Health Medical Affairs Committee, Quality Integration Committee, Behavioral Health, Pharmacy and Credentialing Committees along with National Committee for Quality Assurance (NCQA). For our Medicare advantage members, these are only used in the absence of any NCD or LCD as permitted under the Part C Medicare rules found in Chapter 4 of the Medicare Managed Care Manual.