Priority Health - PriorityActions April 11, 2024 Issue

April 15, 2024

April 11, 2024 Issue #2.7

Latest information on the Change Healthcare outage:
Priority Health sent a PriorityAlert on April 2, 2024  with the latest updates on the Change Healthcare outage.

Change Healthcare communications archive:
You can visit the news & education page in your Provider Manual for an archive of communications we've sent about the Change Healthcare outage. 


Get the 2024 HEDIS® ECDS Provider Guide:

Our new Healthcare Effectiveness and Data Information Set (HEDIS®) Electronic Digital Data Source (ECDS) Provider Guide is now available. This guide will help you better understand HEDIS ECDS reporting and its impact on your patients, your practice and our health plan.

Why is ECDS important?

The National Committee for Quality Assurance (NCQA) implemented ECDS to help move measures toward a more digital future. ECDS reporting is NCQA’s larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures. 

What’s included: 

Each HEDIS ECDS measure includes: 

  • A description of the measure
  • Correct billing codes for claims submissions
  • Tips and best practices to help close care opportunities and improve your HEDIS rate

To access the guide, log into your prism account and navigate to Provider Incentive Programs, then Quality Improvement.  


New provider-based billing reimbursement policy goes into effect June 1:

In alignment with industry standards, we’re updating our provider-based billing reimbursement practices.

What’s changing?

Effective June 1, we’ll no longer separately reimburse for clinic fees or any other fees associated with space used to provide E/M services, when billed on a UB-04 facility claim, regardless of the office being located on the hospital campus and/or using the hospital TIN. 

This update will apply to all commercial and Medicaid lines of business for in- and out-of-network providers and facilities (excluding RHC and FQHC), regardless of reimbursement methodology. 

What do providers need to know?

We’ve published a new provider-based billing policy to support providers in understanding: 

  • What’s included in both non-facility and facility reimbursement rates
  • How these rates apply to a claim based on the place of service (POS) code
  • The conditions under which a claim will be denied

Providers should continue to bill the most appropriate place of service (POS) code for services rendered in their practice setting. 


Facilities: Newborn claims will soon process separately from the mother:

By late Spring, newborn deliveries will be processed separately from the mother for our commercial members. 

You won’t need to do anything different. You’ll continue to bill as you always have. When you receive your remittance advice, you’ll see separate claim lines for the mother and baby. If they process on different weeks, you may see them on separate remittance advices. 

This change is only for our commercial members. There’s no change to how we’re paying or displaying payments for Medicaid members. 


Updates to 2024 PIP Filemart reporting:

The first Filemart reports for the 2024 PCP Incentive Program (PIP) performance year will be released in mid-April. Reporting will include claims paid through Mar. 31, 2024. 

You’ll see the following report updates: 

New report

We’re adding the PIP_003 – ACN Measure Performance (TAB) report to identify your ACN’s performance by measure for: 

  • Current year to date
  • Prior year to date
  • Current year to date performance at the plan level
  • Current year measure target


Retired report

The PIP_070 – Supplemental Data Worksheet is being retired. 


Modified reports


Change in diabetic supply provider network:

Two of our diabetic supply providers are being removed from our network: Healthy Living Medical Supply and Solara Medical Supplies. To ensure our members—your patients—continue to receive the diabetic supplies and equipment they need, please begin referring patients to other diabetic supply providers in the Priority Health network and transfer all current prescriptions to in-network suppliers. 

When is this change taking effect?

Healthy Living and Solara will no longer be in our network effective Aug. 15, 2024. (See below for one exception regarding Medicaid members who use Omnipod® products.) However, authorizations for supplies with these companies will no longer be approved after April 30, 2024. 


Which members will be impacted?

This change impacts commercial and individual, Medicare and Medicaid members who use these two companies. 


Why are we making this change?

We’re removing these two suppliers from our network because they are not able to meet the standards we’ve set for serving our members. 


What do you need to do?

Please begin transitioning your patients’ diabetic supply prescriptions to one of the in-network providers listed below. After April 30, you’ll only be able to refer our members to these companies. If the member already has a prescription with Healthy Living or Solara, along with a valid authorization, the prescription will be honored until Aug. 15. 

What about Medicaid members who use Omnipod products?

Omnipod and integrated continuous glucose monitor (CGM) supplies will continue to be available to Priority Health Medicaid members from Healthy Living and Solara at in-network coverage levels, even after Healthy Living and Solara are otherwise terminated from our network on Aug. 15, 2024. 


What about Medicare members currently renting insulin pumps?

Priority Health Medicare members currently renting an insulin pump from Healthy Living or Solara will be allowed to complete their rental period without disruption and at in-network benefit levels. 


What about CGMs?

For fully funded commercial (group and individual) members, CGMs (excluding Medtronic®) and related supplies will only be covered through pharmacy benefits (instead of through DME vendors and medical benefits) upon their 2024 plan renewal date. The network change communicated here doesn’t impact that previously communicated CGM benefit change. So, if the member’s plan renewal date is before August 15, 2024, that will be the last date to use Healthy Living or Solara to obtain these supplies. 

For Medtronic users and ASO group members who can only obtain their CGMs through the medical benefit, Healthy Living and Solara will no longer be in-network options after Aug. 15. 

See our Provider Manual for more information about CGM policies.