Currentpriority healthPolicy N/A

Concierge medicine participation

Governs how Priority Health allows providers who operate concierge medicine practices to participate, including provider responsibilities, member selection, and actions for noncompliance; affects Priority Health-contracted providers and members (Medicare Advantage references noted).

Policy Summary

Payerpriority health

PolicyConcierge medicine participation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must not bill Priority Health for services provided under the concierge agreement and must accept Priority Health payment as payment in full.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Providers may treat PH memberspermission granted

No billing to PHbilling restriction

Listed in directorydirectory disclosure

Member self-selectionmember assignment rule

Participation and Compliance Criteria

Participation and compliance criteria

Conditions for provider participation and member interactions

ALL of the following

Provider will be allowed to treat Priority Health patients who enroll in the physician's concierge medicine practice.
Provider must enter into a written agreement with each member detailing the terms, conditions and cost of the concierge medical practice.
Provider must not bill Priority Health for any health services provided under the concierge medical practice agreement.
Providers must follow the terms and conditions as set forth in the CMS Guidelines specific to Concierge care; Priority Health Medicare Advantage requirements for proper notice of noncoverage are found in the Provider Manual.

Policy Summary

Payerpriority health

PolicyConcierge medicine participation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must not bill Priority Health for services provided under the concierge agreement and must accept Priority Health payment as payment in full.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing, Codes and Thresholds

No specific codes listedmixed

No codes listed

inv-03: Billing threshold — providers must not bill Priority Health for services covered under concierge agreements

Billing prohibitionProviders must not bill Priority Health for any health services provided under the concierge medical practice agreement.

Provider payment acceptanceProviders must accept Priority Health payment as payment in full and follow contractual payment rules in the Provider Manual and provider contract.

Written member agreementProvider must enter into a written agreement with each member detailing the terms, conditions and cost of the concierge medical practice.

Provider Responsibilities and Required Evidence

Billing Rule

Billing and payment rules for concierge services

Providers must not bill Priority Health for any health services that are included in a concierge (concierge medicine) agreement. Concierge fees charged directly to members are separate from Priority Health-covered services. Providers must accept Priority Health's payment as payment in full for covered services and follow applicable payment rules in their provider contract and the Priority Health Provider Manual.

Do not submit claims to Priority Health for services explicitly covered by the concierge agreement.
Accept Priority Health payment as payment in full for covered services per provider contract and Provider Manual.

Documentation Required

Written member agreement requirement and evidence

Providers must enter into a written agreement with each member that clearly details the terms, conditions, and cost of the concierge medical practice. Priority Health may request evidence of the written concierge agreement if a member complaint or claims concern arises; failure to produce the agreement may result in review by the CMO and the Provider Adverse Action Committee (PAAC).

Written agreement must describe services covered by the concierge fee, membership costs, and any services that remain billable to Priority Health.
Be prepared to provide a copy of the member's signed concierge agreement upon request.
Priority Health will review complaints/claims and may refer matters to the CMO and PAAC if concerns are identified.

Note

Medicare Advantage notice and ABN guidance

Follow CMS guidelines specific to concierge care and Priority Health Medicare Advantage notice of noncoverage rules. Providers must consult the Priority Health Provider Manual for Part C Medicare Advantage ABN guidance — the ABN form and ABN-like forms are for Fee-for-Service Medicare only and may not be used for Medicare Advantage members.

Comply with CMS Concierge care guidance and Priority Health MA notice of noncoverage requirements.
Do not use the FFS Medicare ABN form (or ABN-like forms) for Medicare Advantage (Part C) members; follow Provider Manual instructions instead.

Key Definitions

inv-07: Concierge medicine — definition of concierge medicine and fee arrangement

DefinitionConcierge medicine is a healthcare arrangement in which patients pay an enrollment fee in order to receive care at a medical practice.

Member enrollmentProviders may treat Priority Health patients who enroll in the physician's concierge medicine practice.

Agreement and feesConcierge arrangements require a written agreement with each member describing terms, conditions, and costs.

Medicare Advantage rulesProviders must follow CMS Guidelines specific to concierge care; ABN form cannot be used for Medicare Advantage (refer to the Provider Manual for Part C rules).