Discharging a patient from care
Priority Health expects that providers will not 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 providers to resolve and correct the patient-physician relationship whenever possible, reserving patient discharge as a last resort in instances of abuse.
Discharge vs. reassignment
Discharge: A primary care provider (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 the PCP patient reassignment within a practice page in this Manual 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 a Primary Care Provider Change Form needs to be submitted to Priority Health in order to have the patient removed from the current PCP's membership roster.
To complete a reassignment to a practice outside a PCP TIN, consider the following options:
- The member must complete and sign the PCP Change Form and the office must submit the completed and signed form to Priority Health
- The member can call customer service to change their PCP
- The member can update their PCP online using the member portal
Note: PCP changes are effective the first of the month following the completion of the request to change.
Acceptable reasons for discharge
Unpaid copayments or deductibles:
- Collection period must be a minimum of 90 days.
- Collection attempts must be documented in the patient's chart.
Repeated "no-shows" for scheduled appointments:
- Defined as three or more 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.
"Doctor-shopping" to obtain prescriptions: Details of this activity should be documented in the patient's chart, including dates of visit or contact with the member.
Failed drug screen, in violation of practice illegal drug-free policy: Date of drug screen and policy must be documented in the patient's chart.
Fraudulent behavior: Case documented in the member's record.
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.
Primary care providers must follow these steps to discharge a member from their practice:
- Document the reason(s) for requesting discharge within the patient's medical record.
- Document all resolution attempts within the patient's medical record.
- Notify the patient in writing that he or she has been discharged from your practice.
- You must offer 30 days of urgent/emergent care to the patient following the date of the discharge letter.
- Request the discharge from Priority Health using our online Patient Profile tool. See below.
- Priority Health reassigns the member to a new PCP. The PCP assignment will be effective on the date submitted to Priority Health. Discharge may take up to 30 days to process.
View the full Discharge a patient from care policy.
Other reports we provide to you may not match PCP changes to membership lists. This is because the timing for our reports differs and different rules may apply. For example, members may be included in an "anchored" incentive measure like immunizations, which must be achieved by a member's specific birthday. Members assigned to a PCP at the time of the birthday will appear on the PCP Incentive Program reports and be included in the measure calculation for that PCP, even if they were reassigned after that birthday.
Periodically, Priority Health may conduct audits of discharge requests and ask for copies of the documentation required by the discharge policy.
Using Patient Profile to discharge a member
- Log in to your prism account.
- Click Resources in the main menu and then click Patient Profile.
- Click Patient Search.
- Fill in either the contract number or member's last and first name. Click the Search button.
- Choose the member to discharge.
- From the dropdown menu, select Patient Profile.
- Click the update data button.
- Scroll to the bottom of the page and click the Discharge a patient from care button.
- Choose the reason for discharge and the date of discharge. Click Continue.
- You'll receive a transaction number confirming that you submitted the request.