Currentpriority healthPolicy N/A

Balance Billing

This policy defines balance billing rules for Priority Health providers, describing when providers may bill members for differences between charges and plan payment, disclosure requirements for out-of-network care, reimbursement rules for certain out-of-network specialties, and dispute processes. It primarily affects participating and non-participating providers delivering services to Priority Health members in Michigan.

Policy Summary

Payerpriority health

PolicyBalance Billing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 1, 2026

Key ActionFor indications that don't meet NCD, LCD or specific medical policy a Pre-Service Organization Determination (PSOD) may be required; see Provider Manual for PSOD information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

150% MedicareReimbursement rate floor for out-of-network PARE providers

30 daysOpen negotiation period for payment disputes

MI Bills 4459/4460State resources referenced

Apr 2026Policy review date

Balance Billing Rules and Procedures

Balance billing rules and procedures

Rules governing balance billing, required disclosures, reimbursement for certain out-of-network specialties, dispute resolution, and documentation obligations.

Participating providers may not balance bill patients for covered services, per contract.

Balance billing is prohibited for emergency services; providers may not balance bill for emergency care.

ALL of the following

Disclosure must include a statement that the insurer may not cover all services.
Disclosure must include a good-faith estimate for the services to be provided.

Policy Summary

Payerpriority health

PolicyBalance Billing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 1, 2026

Key ActionFor indications that don't meet NCD, LCD or specific medical policy a Pre-Service Organization Determination (PSOD) may be required; see Provider Manual for PSOD information.

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, Coding, and Documentation Requirements

Billing and coding requirementsmixed

No codes listed

Documentation sufficiency

Documentation expectationComplete, thorough documentation to substantiate the procedure or service is the provider's responsibility.

Consequences of inadequate documentationFailure to document services or items supplied will result in claim denial.

Recoupment riskPriority Health may recover or recoup claim payment if program regulations, policy, or contractual requirements aren’t followed.

Payment integrity reviewsPayment integrity pre- or post-claim reviews may be performed to validate billing and coding accuracy and to prevent fraud, waste, and abuse.

Authorization does not guarantee paymentAn authorization on file does not supersede coding, billing or reimbursement requirements; proper billing and coding must still be followed.

Key Definitions

Balance billing

DefinitionBalance billing is billing the patient for the difference between what Priority Health pays for a covered service and the provider’s charge price for that service.

Participating provider ruleParticipating providers may not balance bill patients for covered services per their contract.

Out-of-network disclosure requirementOut-of-network providers must disclose potential for balance billing before non-emergent services, including insurer coverage limitations, a good-faith estimate, option to request in-network care, and obtain a signed acknowledgement.

Emergency servicesBalance billing is not allowed for emergency services; failure to disclose for non-emergent services may prohibit balance billing by law.

OpenPayer

Balance Billing

Balance Billing Rules and Procedures

Billing, Coding, and Documentation Requirements

Pre-Service Determination and Provider Responsibilities

Key Definitions