REQUIREMENTS AND RESPONSIBILITIES
November 2024 medical policy updates
Our Medical Advisory Committee (MAC), comprised of Priority Health network physicians, met in November and approved a series of medical policy updates. Below is a summary of the updates made.
New medical policies & policies addressing updated coverage
TRAINING OPPORTUNITIES
Register now to learn about our Jan. 1 formulary changes on Nov. 21
Join us for a webinar to learn more about upcoming formulary changes for all Priority Health plan types, as well as other pharmacy updates. This session will cover:
Thank you all so much for joining us at this year's Payor Conference. We are always so thrilled to be able to spend some time together. As promised, attached are the slide decks from the payors who were present.
LMOA is an independent, non-profit organization dedicated to providing quality education to southwestern Michigan's healthcare community.
The Lakeland Medical Office Association invites you to attend our November luncheon and seminar.
Title: Human Trafficking
Upon completion of the training, participants will be able to:
Priority Health has provided a few documents that will help offices navigate their processes. Attached are two information sheets on PRISM and one information sheet on how to get office questions answered while navigating the Priority Health system
In this October 10, 2024 issue :
* Reminder: You must complete our 15-minute, CMS-required D-SNP Model of Care training
*Reminder: You must complete our 15-minute, CMS-required D-SNP Model of Care training
*Void claims now appear on remittance advice with original claims
*Reminder: Informal claim reviews are required before appeals
*Southwest Michigan providers: Medicaid rebid changes do NOT impact Medicare
*Southwest Michigan providers: Do not turn away any Priority Health members based on their plan type. Please continue to see new and existing Priority Health patients with any plan you participate with, checking their eligibility before you see them just as you did before.
*Register now to learn about our 2025 DBM program on Oct. 29
*Incentive programs
MIOSHA and Lakeland Care Network, in collaboration with Corewell Health Lakeland invite you to share a cup of coffee and learn about the importance of workplace safety and health.
‘Coffee with MIOSHA’ events provide an informal opportunity for employers and employees to meet with MIOSHA representatives (consultative and enforcement) to ask questions, obtain information on program services and resources, learn about the MIOSHA Training Institute (MTI) opportunities, and establish rapport.
The Lakeland Medical Office Association invites you to attend our October luncheon and half-day meeting, sponsored by the Lakeland Care Network.
Program: Lakeland Care Network’s Annual Payor Conference
This year’s Payor Conference will feature the major payors in our market – including those who have Commercial, Medicare, Medicaid and Dual-eligible products. Lakeland Care will also provide an update on our network's current projects and future initiatives.
In the September 26th issue, Priority Health discusses the following topics:
*Register now to learn about our 2025 product updates on Oct. 17
*We’ve added exclusion criteria to our SUPD provider tipsheet
*Have you visited our Quality Improvement page?
*Reminder: groups must now have a pSA to affiliate prism users
*Helping alleviate fall risks for your Medicare patients
*Get our 2024 member outreach calendar
*Prescription Drug Take Back Day coming Oct. 26
*Encourage your patients to try Teladoc Health Mental Health
Attached you will find this month's update to provider offices that will be faxed to offices. Please be on the look out for them to arrive in your offices.
There are a number of attachments below that discuss HIV as well as the most recent Provider Bulletin No 220.
Provider Bulletin 219 discusses what offices need to do in order to transfer EFT remittance advice services to ECHO Health.
An estimated 38,000 Americans are newly diagnosed with HIV each year, with a disproportionate amount of new diagnoses taking place within marginalized and low-income communities. We want to partner with you to help reduce HIV diagnoses and increase suppression rates across the state of Michigan and our Medicaid population.
INCENTIVES-
Updated 2024 PIP Manual available
Priority's Radiation Oncology Authorization Program with EviCore Launches September 15
The Lakeland Medical Office Association invites you to attend our September luncheon and seminar.
Title: Conducting Effective Interviews – How to Get the Right Person for the Job
Priority Health lost their bid for Michigan’s Region 8 to be a Medicaid payor. Molina lost their bid as well. Region 8 is comprised of the following Michigan counties: Berrien, Cass, VanBuren, Kalamazoo, Calhoun, St. Joseph, and Branch.
Corewell Health once again offers drive-through community flu clinics in Southwest Michigan. Flu shots are available to adults ages 18 and over with no appointment necessary.
The Centers for Disease Control and Prevention recommends a yearly flu vaccine for everyone ages six months and older as the best protection from this serious illness. Lakeland Care Network (Lakeland Care), in collaboration with Corewell Health, will offer drive-through community flu shots starting on September 12, 2024 and ending on October 11, 2024.
Attachment provided by ABH as a reference tool for your offices.
To better serve our pediatric members, Aetna now offers an annual incentive to successfully enrolled VFC providers servicing children ages 19 and under as part of our Pay-for-Quality (P4Q) Program
-August 2024 medical policy updates: Benign Prostatic Hyperplasia (BPH) Treatments, Infectious Disease Molecular Panels, Infectious Disease Molecular Panels
-Moving to InterQual® criteria
-Added prior authorization requirement: Varicose Vein Treatment
-Updated payable units: Breast Related Procedures
-Updated prior authorization guidance: Genetics: Counseling, Testing, Screening
-Additional medical policy updates: Policy updates effective Sept. 1, 2024
-Authorizations:Start submitting cardiac & MSK authorization requests to TurningPoint today
-New reports to help close osteoporosis care gaps
-OMW gap closure
-Learn more about our fall quality initiatives
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Priority Health has shared a document for offices to help navigate their questions and how to successfully resolve any issues.
Please share with your fellow office teammates!
A Special Edition Update from McLaren Health Plan:
As we continue to navigate the impact to our operations due to the cyber-attack, we are making progress restoring our systems and services. Below is an update on key items:
Customer Service
The McLaren Health Plan Member and Provider Call Center is operational, although they may not have access to all systems, they can provide assistance and direction.
McLaren Connect Provider Portal
*Medicaid rebid impacts on providers in Northern and Southwest Michigan
*Starting September 23, groups must have a pSA to affiliate prism users
*Reminder: You must complete our 15-minute CMS-required D-SNP Model of Care training
*APCD replacement files will be delivered via SFTP starting August 15
*Resources & trainings for TurningPoint authorizations programs
*Provider trainings for EviCore’s radiation oncology authorizations program
*Finalizing 2024 InterQual® criteria transition
*New coding policies posted to the Provider Manual
UnitedHealthcare Selected to Serve Medicaid Members in Michigan Through the Comprehensive Health Care Program
Eligible adults and children will have access to UnitedHealthcare Medicaid services and benefits in six regions
The Michigan Department of Health and Human Services (MDHHS) has selected UnitedHealthcare Community Plan of Michigan as one of the nine managed care organizations to administer the Comprehensive Health Care Program (CHCP).
What do these drugs treat?
Ogivri and Ontruzant are both biosimilars for Herceptin® and are used to treat breast cancer, gastric cancer and esophagogastric cancer.
How will this impact you?
Ogivri: For our commercial group, individual and Medicare Advantage members, Ogivri will be covered under the medical benefit with no prior authorization requirements effective August 1.
Ontruzant:
For commercial group and individual members, Ontruzant will remain a non-covered drug. If you’d like to seek treatment with Ontruzant for your patients, prior authorization is required.
For Medicare Advantage members, Ontruzant will remain a covered drug with prior authorization requirements, which include trials of both Ogivri and Trazimera.
* Get our Q3 Physician and practice news digest and our Q3 Medicare/Medicaid Quality newsletter
*Take action today before your staff loses access to prism
*How do I complete the pSA renewal process?
* Reminder: Unique NPI required for rehab groups to credential BH providers
* Coding policies going into effect September 23, 2024
* Do your Medicare patients qualify for Extra Help?
* Register now to learn about our Q4 Medicare/Medicaid Quality campaigns on August 29, 2024
Aetna Better Health has sent paper copies to offices and has provided LCN this electronic copy of the Spring 2024 Provider Newsletter.
July 2024 UHC Updates:
*New prior authorization requirements for Continuous Glucose Monitors
*Updates to oncology and hematology prior authorization codes for many plans
*Michigan: Prior authorization updates for provider administered medications
*July 2024 Preferred Lab Network list is now available
*Annual federal audit of commercial plans
*Add your merchant ID in My Practice Profile
*Complete special needs plan MOC training by Dec. 31
*Digital Solutions
*Policy and protocol updates See the updates
Priority Health - PriorityActions for providers update July 11, 2024
*Resource to address GLP-1 shortages and support patient medication adherence
*July VOA roundup: watch new Modules and register for upcoming webinars
*Provider trainings for TurningPoint authorizations programs
*Reminder: Attest to your providers’ PCMH designations in PRA
*Prism inquiry turnaround times and when to reach out to our team
*Get free vaccines for your eligible patients through the Vaccines for Children Program
*Register now to learn about our 2025 PCP Incentive Program on July 11, 2024
*Reminder: you must refer members to in-network providers, including labs
Get free vaccines for your eligible patients through the Vaccines for Children Program!
What’s the Vaccines for Children (VFC) Program?
The VFC program is a federally funded program offered through the Michigan Department of Health and Human Services (MDHHS) that provides you with vaccines, at no cost, for your Medicaid-eligible patients ages 0 through 18. VFC program providers get free vaccines for eligible patients and are reimbursed for vaccine administration.
Want to know more?
Barry-Eaton District Health Department (BEDHD) and Michigan Department of Health and Human Services are investigating 3 cases of Legionnaires’ disease (LD) associated with Bay Pointe Inn located in Barry County. The cases reported travel to Bay Pointe Inn (11456 Marsh Rd, Shelbyville, MI 49344) between March 2024 and June 2024.
Meridian discovered an internal issue this morning, June 12, 2024. There were several claims denied for CHAMPs eligibility. Offices likely would have seen those denials as F6 or F7. Meridian was able to stop the majority of the claims prior to going out, but unfortunately some had already gone out denied. The problem was due to a broken internal file interface.
PriorityActions June 6, 2024 Issue. Please visit the Priority Health provider site for full details and updates to the following:
Authorizations, new radiation oncology authorizations programs, incentive programs, pharmacy, requirements and responsibilities, billing and payments,and training opportunities.
New MSK authorizations program will launch September 2024
In addition to cardiac managed care, we’re also partnering with TurningPoint on a new authorizations program for musculoskeletal (MSK) procedures, both slated to launch September 2024.
These programs are designed to facilitate provider-to-provider collaboration on each member’s care plan, with the overall goal to optimize health outcomes and work more closely with you, our provider partners, on evidence-based, value-driven care.
Updates to Emergency Department Facility Evaluation and Management Coding Policy effective July 1, 2024.
Highlighted in this issue are: Incentive programs, Updated 2024 HEDIS guidelines, Updated 2024 PIP manual, May 2024 Medical Policy Updates, Mandatory pSA Renewal process begins June 1, 2024, Reminder to follow ICD-10 guidelines, and Virtual Office Advisory Training on June 13
Blue Cross Blue Shield of Michigan and Blue Care Network will be announcing the alignment of Blue Cross physician organizations and BCN medical care groups in provider newsletters.
The latest issue of PriorityActions for May 9, 2024 include:
*Change Healthcare outage update: Electronic RAs resumed through Change Healthcare and Optum clearinghouses; all services should be restored
*We’re transitioning to 2024 InterQual® criteria starting July 15
*We’re no longer allowing providers to be enrolled under multiple ACN contracts with the same NPI, TIN and address
*We’re requesting medical records for an MDHHS audit
*We’re reprocessing incorrectly rejected Tdap vaccine claims
Meridian has partnered with Evolent (formerly New Century Health) to implement a new prior authorization program. Evolent is a comprehensive Cardiology Quality Management Company. This program is intended to help providers easily and effectively deliver quality patient care.
Effective June 1, 2024, invasive cardiology procedures and services will require prior authorization through Evolent rendered in a physician’s office, outpatient hospital, ambulatory, or inpatient setting (planned professional services only) will require prior authorization through Evolent.