Applies to:

Commercial group HMO, EPO, POS and PPO plans

Commercial individual MyPriority® plans

Coverage for Priority Health Medicare Advantage members

Priority Health Medicare Advantage members are free to participate in any qualifying clinical trial that is open to Medicare beneficiaries in Original Medicare. Clinical trials are covered under Clinical Trials National Coverage Determination (NCD). Refer to the Medicare Clinical Trial Policy.

Original Medicare pays for the cost of routine services provided to a Priority Health Medicare member who joins a qualifying clinical trial. Providers should bill Original Medicare. 

Medical policy/policies

• Clinical Trials - 91606
• Clinical Trials for Self Funded Groups Opting Out of PPACA - 91448

Clinical trial authorizations

Prior Authorization is required for out-of-network services

Clinical trials billing

Claims submitted for clinical trials with modifier Z0 or Z1 service must be accompanied by diagnosis code Z00.6 (Encounter for examination for normal comparison and control in clinical research program). Claims submitted with these modifiers without the Z00.6 diagnosis code, in addition to any other diagnosis codes reported, will be denied. This is applicable to all products. You must report this diagnosis even when you've received an authorization.