Discharging a patient from their assigned PCP

Priority Health expects that providers won’t discriminate against members because of race, color, ancestry, religion, age, gender, national origin, marital status, health status or disability.

Member discharge is a serious matter. We encourage primary care providers (PCPs) to resolve and correct the patient-physician relationship whenever possible, reserving patient discharge as a last resort in instances of abuse. 

Note: Discharging / reassigning a member won’t affect the member’s attributed PCP for our value-based programs, including the PCP Incentive Program (PIP), the Disease Burden Management Program (DBM) and Alternative Payment Model (APM). This is because our value-based programs use our member attribution model, which is based on claims. Because of this, your value-based program reports may differ from your membership lists. See our Provider Incentive Programs webpage (login required) for details on the member attribution process.

Discharge vs. reassignment 

Discharge: A PCP withdraws from serving as a PCP to a particular patient.

Reassignment to a practice inside a PCP TIN: Patient reassignment only occurs when a patient is moving to another PCP within the TIN. See our PCP patient reassignment within a practice page for details.

Reassignment to a practice outside a PCP TIN: When a patient requests to transfer their records to another PCP outside of their current PCP's TIN, the following options are available:

  1. The member completes and signs the PCP Change Form, which the office then submits to Priority Health.
  2. The member calls customer service to change their PCP.
  3. The member updates their PCP online using our member portal.

Note: PCP changes are effective the first of the month following the completion of the change request.

Acceptable reasons for discharge

Unpaid copayments or deductibles:

  • The collection period must be a minimum of 90 days.
  • Total unpaid copayments or deductibles must be a minimum of $150.
  • Collection attempts must be documented in the patient's chart.

Repeated "no-shows" for scheduled appointments:

  • Defined as three or more consecutive visits missed in a twelve-month period
  • Dates of no-shows must be documented in the patient's chart.

Threatening behavior displayed toward practice staff: Behavior and practice response must be documented in the patient's chart. Examples of threatening behavior include verbal abuse or threats of violence, exhibiting physical violence or other inappropriate behavior. A member cannot be discharged for non-compliance with treatment plans.

Fraudulent behavior: Case documented in the member's record. Fraudulent behavior involves theft or criminal activity involving the practice (i.e., theft of a prescription pad).

How to discharge a member

Once submitted online, a member discharge request may take up to 30 calendar days to process.

The discharge process applies to members of all Priority Health products. The Center for Medicare and Medicaid Services (CMS) and the State of Michigan Medicaid program guidelines may override portions of this policy for Medicare, Medicaid and Healthy Michigan Plan members.

PCPs must follow these steps to discharge a member from their practice:

  1. Document the reason(s) for requesting discharge within the patient's medical record.
  2. Document all resolution attempts within the patient's medical record.
  3. Notify the patient in writing that they've been discharged from your practice.
  4. Offer 30 days of urgent/emergent care to the patient following the date of the discharge letter.  
  5. Request the discharge from Priority Health in prism, our online provider center. See below for step-by-step instructions.

Once this process is complete, Priority Health reassigns the member to a new PCP with an effective date of the first of the month following the change request.

Submit a patient discharge request in prism

  1. Log in to your prism account.
  2. Click Member Inquiry in the main menu.
  3. Look up the member in question. Either enter their member ID under Search by Contract Number or toggle over to the Search by Name and Date of Birth tab to search there. Click Search.
  4. Click the name of the member in question.
  5. About halfway down the screen, you’ll see dropdown menus to Select Contract Period and Select Contract Number. Verify that the current coverage term and the contract number for the plan type to be discharged are selected.
  6. Click the Discharge Member button.

    Can't click the Discharge Member button? There are a couple reasons the button may be disabled and discharge isn't possible:

    - Your prism account isn’t connected to the member’s PCP practice group.
    - The member doesn’t have an assigned PCP on file.
    - The member’s plan is inactive or set for a future date

  7. On the resulting pop-up, select the reason for discharge and the date of discharge. Click Next.
  8. Attach documentation that supports / proves the selected member discharge reason (this is required). Click Done, then click Next in the File Attachment window. You’ll see a Success message confirming the member discharge submission.

You can review the request in the General Requests section of prism. When the discharge is complete, the inquiry’s Status column will say Closed.

See the instructions with prism screens included