Commercial group HMO, EPO, POS and PPO plans
Commercial individual MyPriority® plans
Coverage for Priority Health Medicare Advantage members
Priority Health Medicare Advantage members are free to participate in any qualifying clinical trial that is open to Medicare beneficiaries in Original Medicare. Clinical trials are covered under Clinical Trials National Coverage Determination (NCD). Refer to the Medicare Clinical Trial Policy.
Original Medicare pays for the cost of routine services provided to a Priority Health Medicare member who joins a qualifying clinical trial. Providers should bill Original Medicare.
Clinical trial authorizations
Prior Authorization is required for out-of-network services
Clinical trials billing
Claims submitted for clinical trials with modifier Z0 or Z1 service must be accompanied by diagnosis code Z00.6 (Encounter for examination for normal comparison and control in clinical research program). Claims submitted with these modifiers without the Z00.6 diagnosis code, in addition to any other diagnosis codes reported, will be denied. This is applicable to all products. You must report this diagnosis even when you've received an authorization.