Annual reminder: you must refer members to in-network providers, including labs

To help ensure our members get the highest quality, most affordable health care through our network partners, you’re required to use labs that participate in our network. Participating providers have a contractual obligation to use in-network providers when referring our members for services, regardless of your own contracts for referrals with non-participating labs.

Out-of-network labs are not covered for members with HMO plans without an approved authorization, even if the lab is performed on the same day as an office visit with a participating provider.

If an HMO member chooses an out-of-network lab despite the provider’s guidance, the member is responsible for the payment. Under Michigan’s surprise billing legislation, for this to occur, the member must sign documentation from the provider that includes:

• A statement that their insurer may not cover all services
• A "good-faith" estimate for services to be provided
• A statement that the member may request care from an in-network provider and can contact their health plan to discuss

What should providers and facilities do?

Refer your patients to in-network providers and facilities. Use our Find a Doctor tool on priorityhealth.com to find labs that are in-network for your patient’s unique plan. If an out-of-network lab is the only option, follow the steps to request an authorization.

If a Priority Health member chooses to use an out-of-network provider or facility without prior approval, inform the member in writing that they will be responsible for any costs, and ensure you have a documented signature from them affirming their choice.

If an out-of-network lab is necessary for a particular service, a prior-authorization is required. Learn more about reference lab billing. 

We’re always here to help

If you can’t find an in-network lab using the Find a Doctor tool, contact the Provider Helpline at 800.942.4765.