News

Effective June 2, 2025, Priority Health will NOT review post-claim appeals for medical necessity when a denied authorization is on file for the following authorization types, for all lines of business:
• Outpatient, home health & DME
• Elective inpatient
• Behavioral health

Note: This change doesn’t apply to inpatient acute / urgent / emergent or post-acute authorizations.

This applies when you’ve requested an authorization, received a denial for medical necessity and performed the service or procedure. Services / procedures performed with a denied authorization become provider liability. This change is in alignment with industry standards.

Beginning June 2, 2025, Priority Health will use 2025 InterQual® criteria to make medical necessity determinations on prior authorization requests to ensure their members are getting the right care, at the right place and at the right time. The types of authorizations that are affected are below.

Lakeland Care Network together with Corewell Health Lakeland have pharmacists available to serve your patients. Our clinical pharmacists can help with medication reviews, adjustments, and savings all while reducing potential side effects. We manage a variety of conditions from diabetes and high blood pressure to COPD, osteoporosis and others. Call us to schedule or ask your physician for a referral.

United Healthcare provides updates on their Specialty Medical Injectable Drug Program and their Prescription Drug List.

Corewell Health Lakeland's diabetes and nutrition team is ready to help you take control and manage your health. We offer everything from diabetes education and nutrition guidance, to group classes and personalized health plans. Our education team offers our services in St. Joseph, Niles, and Watervliet.

On April 16, 2025 the Lakeland Medical Office Association invites you to join us for lunch and a presentation on "Disclosure of Unanticipated Outcomes." Details are below.

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 March luncheon and seminar presented by WPS**

Please review the Aetna Better Health attachments sent via fax blast or USPS mail to all providers.  Please share with your staff. 

• Provider Letter: Prior Authorization change  - Codes now requiring prior authorizations effective 2.15.2025

   

•  Provider Letter:  Aetna Better Health new physical address change only– effective 1.15.2025

  2 Towne Square Suite #275

  Southfield, MI 48034

New and updated billing policies are now available

We publish billing policies to offer transparency and help you: 

Please read the following UHC Network News mid February update to catch up on the latest UHC changes.
* Prior authorization changes
* UHC Provider Portal updates
* Miscellaneous news
* Support Black History Month through health equity
* Electronic submission required for claim reconsiderations

Blue Cross and BCN announce the availability of a new MCG webpage within the current Blue Cross Blue Shield of Michigan Provider Collaboration Portal. This new webpage will be available, Wednesday, Feb. 19, 2025, and will provide you with one location to find announcements, documents and events related to your Blue Care Network and BCN AdvantageSM contracts.

 An informational session covering site features, functionality and user access will be held on Wednesday, Feb 19, 2025, from 11:30am to 12:30pm. Please plan to attend this session to learn how to use this new site.

* New authorization requirement for renal denervation, effective Apr. 6, 2025
* Reminder: Call backs aren’t available for missed peer-to-peers for inpatient cases
* Seeing why a claim denied is now easier than ever in prism
* Reference prism for denial details instead of ERA/835 files
* Updated 2025 PIP & DBM manuals are available
* Rationale for excluding ASO / PPO from 2025 PIP Transformation of Care measures
* Register now for our February 20 product tips & reminders webinar
* 2025 D-SNP MOC training is now available
* We’re allowing more time for audit appeals, effective Jan. 1, 2025
* Get at-home colorectal cancer test kits for your eligible Priority Health patients
* Get our winter Physician and practice news digest and our Medicare/Medicaid Quality newsletter

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 February luncheon and seminar. 

* Streamline your workflow: Availity Essentials adds IPA and delegated entities
* New rule improves prior authorization process
* New study shows CenterWell Pharmacy benefits heart failure with reduced ejection fraction patients
* Artificial intelligence adoption in the
value-based era
* NEW! Watch the Stars condition management overview video
* Complete your required 2025 training
* NEW! Go365 provider toolkit puts patient well-being front and center
* The holidays and substance use disorders

February 01, 2025 Monthly Overview

UHC Network News is published twice a month. See updates below.

Policy and protocol updates

Medical policy updates
Medical policy updates for February 2025 for the following plans: Medicare, Medicaid, Exchanges and commercial.

* Updated TurningPoint provider training guide now available
* Medicaid formulary changes coming Feb. 1, 2025
* Register now for our January 30 billing & coding webinar
* NCQA’s 2025 HEDIS audit is underway
* Reminder: HMA members have access to Priority Health’s network

* Non-urgent inpatient hospital transfers will require prior authorization before transfer starting Mar. 10, 2025
* New & updated billing policies are now available
* Reminder: Corrected claims must include the original claim ID

HEDIS & PIP reporting updates for the 2024 and 2025 performance years

We’re sharing several updates related to HEDIS and PCP Incentive Program (PIP) reporting: 

2024 performance year information

December Filemart reports include historical data
Your December 2024 PIP reports include historical data, including care gap closure and member exclusions for the following multi-year measures: 

Please review the updated attachments sent via fax blast or USPS mail to all providers.  

• Provider Letter: Edifecs Smart Trading platform - effective 1.20.2025
  
  • Enhancing claims EDI intake editing
  • Provider EDI claim submission processes will NOT be affected by this change

The Lakeland Medical Office Association invites you to attend our January luncheon and seminar.

Title:   Connecting Through Social Styles:  Strengthening Teamwork in the Office

Speaker:          Kim Olson, Sr. Organizational Development Specialist
HR Talent and Culture, Corewell Health South

Date:                  Wednesday, January 15, 2025

Highlighted in this issue of PriorityActions:
*New resources available for the HMA product, launching January 1
*Reminder: the best way for practices to communicate with us is through prism

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