Providers

Lakeland Care network has had several contracts with United Healthcare for 15 years. We have a Commercial contract, a Medicaid contract with United's Community Plan, a Medicare contract for Veterans Affairs Community Care Network, and a Duals contract for their UHC Dual Complete Medicare Advantage.  However, through all these contracts, mental health has been very difficult for UHC to administer correctly. Therefore, Lakeland Care network providers who wish to see United Healthcare patients for any of their products need to contract directly with Optum.

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