To help ensure their members get the highest quality, most affordable health care through their network partners, you’re required to use labs that participate in Priority Health’s 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 out-of-network lab is necessary for a particular service, a prior-authorization is required. (Learn more about reference lab billing here.)

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

Click here to read the full article on the Priority Health website.