REQUIREMENTS AND RESPONSIBILITIES
August 2024 medical policy updates
Our Medical Advisory Committee (MAC), comprised of Priority Health network physicians, met in August and approved the medical policy updates described below.
Please note the individual policy effective dates listed below and see the medical policy changes page in our Provider Manual for additional details and policy links.
New medical policies
Benign Prostatic Hyperplasia (BPH) Treatments (#91642)
Policy updates effective Nov. 1, 2024
This new policy consolidates Priority Health’s position on the range of BPH procedures, including procedures previously in two separate policies, to be retired:
- Prostatic Artery Embolization for Benign Prostatic Hyperplasia (#91620)
- Prostatic Urethral Lift & Transurethral Water Vapor Therapy for BPH (#91626)
When the policy goes into effect, the following procedures will no longer be covered:
- Transurethral microwave thermotherapy (CPT 53850)
- Transurethral needle ablation of the prostate (CPT 53852)
- Permanent urethral stent (CPT 52282)
Infectious Disease Molecular Panels (#91643)
Policy updates effective Sept. 1, 2024
This new policy was developed to address the growing number of large molecular panels for respiratory and genitourinary infectious diseases. The policy provides medical necessity criteria to outline appropriate use, without changes in coverage or prior authorization requirements.
Moving to InterQual® criteria
Electroencephalography (#91510)
Policy updates effective Nov. 1, 2024
- Moving to InterQual criteria: Current medical necessity criteria have been removed and InterQual criteria adopted. Priority Health may consider VEEG medically necessary when the applicable InterQual criteria are met (CP: Procedures subset Video Electroencephalographic (EEG) Monitoring). Note: Priority Health’s medical necessity criteria mirrored InterQual criteria, so providers shouldn’t experience a change.
- Policy scope is now as follows: This medical policy only addresses video electroencephalographic (VEEG) monitoring with video, conducted at home, at a freestanding center or in a hospital-based facility.
Added prior authorization requirement
Varicose Vein Treatment (#91326)
Policy updates effective Nov. 1, 2024
Certain procedures or services will require prior authorization following InterQual criteria. See the medical policy for a list of applicable procedures or services.
Updated payable units
Breast Related Procedures (#91545)
Policy updates effective Nov. 1, 2024
Criteria were added for autologous fat transplant (harvesting and grafting) for breast reconstruction. Injection of fat cells is limited to 150 cc per breast per procedure due to necrosis or resorption of injected fat cells from high volume fat grafting. Unit limitation of 2 will be placed on CPT 15772 when billed with a diagnosis code related to breast reconstruction.
The Breast Specific Gamma Imaging (#91568) policy was retired as a standalone policy with language added to this policy.
Updated prior authorization guidance
Genetics: Counseling, Testing, Screening (#91540)
Policy updates effective Nov. 1, 2024
Expanded non-invasive prenatal testing for fetal aneuploidies trisomy 21, 13 and 18 to twin pregnancies; removed provider specialty for ordering, counseling and education. Updated prior authorization guidance for tests associated with EviCore management or the Fertility rider. Updated formatting to improve readability and updated terminology to reflect current usage.
Additional medical policy updates
Policy updates effective Sept. 1, 2024
The following policies were updated to clarify language and experimental and investigational positions, or to align with updated industry standards:
- Cranial Helmets (#91504)
- Detoxification (#91104)
- Hyperbaric Oxygen Therapy (#91151)
- Hyperhidrosis (#91451)
- Infertility Diagnosis and Treatment / Assisted Reproduction / Artificial Conception (#91163)
- Neuropsychological and Psychological Testing (#91537)
- Skin Conditions (#91456)
AUTHORIZATIONS
Start submitting cardiac & MSK authorization requests to TurningPoint today
Our new authorization programs with TurningPoint launched on Tuesday, August 20 for cardiac and MSK services taking place on and after Sept. 1, 2024.
Be sure to check if you have surgeries already scheduled that will now require authorization. Review the impacted code lists to see which services and procedures are now managed by TurningPoint on our members’ behalf. Bolded codes are those that don’t currently require authorization but will for dates of service on / after September 1.
For impacted services scheduled on and after Sept. 1, 2024, submit your authorization requests to TurningPoint. Below is an FAQ to support your success:
How do you submit an authorization in TurningPoint?
Our provider portal, prism, will automatically redirect you to TurningPoint to complete authorization requests when appropriate – no separate login needed. Find step-by-step instructions in our TurningPoint provider training guide.
What if you’ve already submitted a request through GuidingCare?
If you’ve already submitted an authorization request to Priority Health through GuidingCare, there’s no need to resubmit through TurningPoint. Your existing authorization request will be honored.
What if you’re requesting a service taking place before September 1?
For services taking place before September 1, you’ll still be directed to TurningPoint’s portal to submit the request. TurningPoint’s team will immediately forward your request to Priority Health for review. TurningPoint will also send you a fax to let you know your case has been forwarded.
Once the faxed request is received by Priority Health, our team will load it into GuidingCare. You’ll be able to check on your request there once this process happens.
Where can you find clinical guidelines?
Authorization requests for cardiac and MSK services taking place on and after September 1 will be reviewed by TurningPoint using their clinical guidelines. You have two ways to access these guidelines, via your prism account:
- Under the Authorizations tab, click Authorization Criteria Lookup. Then click the link for TurningPoint criteria.
- When submitting a request for a procedure managed by TurningPoint, you’ll be routed to TurningPoint’s provider portal automatically. There, you can find clinical guidelines under the Procedures tab.
Where can you learn more?
Visit our TurningPoint resources webpage, which includes FAQs, impacted procedure codes, turnaround times, peer-to-peer appeals information and more. To access this landing page, log into your prism account. Under the Authorizations menu, click Request an Authorization. On the resulting page, click Auth request help page then Get TurningPoint resources.
What can you do if you have questions?
- Reach out to TurningPoint directly – contact information for their Provider Relations team is available on page 3 of the TurningPoint provider training guide.
- Attend an “office hours” session – join us on September 4 or 11 between 11 a.m. – 12 p.m. ET on Zoom where TurningPoint and Priority Health’s provider relations and medical teams will be available to answer your questions.
Are provider trainings available?
Yes! If you missed our August 14 training webinar, there are still three opportunities to join our utilization management team and TurningPoint staff to learn about the authorization programs, as well as how to navigate and successfully request authorizations through TurningPoint.
Registration is open for the following dates, which each session starting at 12 p.m. ET:
- August 21
- August 28
- September 4
PRIORITY HEALTH NEWS
New reports to help close osteoporosis care gaps
To help improve health outcomes and support gap closure in the Osteoporosis Management for Women Who Had a Fracture (OMW) HEDIS measure, our Medicare Quality team has compiled a list of patients who are still in need of testing and or therapies to help manage osteoporosis. We’ll be sending you these reports at the beginning of each month so you can distribute them to impacted providers.
OMW gap closure
To close OMW care gaps, providers must either have their applicable patients complete a bone mineral density (BMD) test or prescribe them a drug to help treat osteoporosis. Note: To close this care gap with an osteoporosis medication, members must process their prescription using their Priority Health Part D coverage. Processing a prescription using pharmacy discount programs or manufacturers’ coupons won’t count toward gap closure. For information on our covered osteoporosis drugs, visit our Medicare approved drug list.
Provider tips for closing OMW care gaps:
- Educate your patient on where/how to schedule their BMD test and emphasize the importance of completing the test within the six-month window. Does your patient need help getting to appointments? Our Medicare Advantage members are eligible for transportation assistance through the Papa pals program.
- Ensure your documentation is accurate and complete. Check out our OMW HEDIS measure spotlight for information on coding requirements for this measure.
- Encourage your patients to alert you if they suffer a fracture to allow for timely intervention and testing. Note: Fractures to fingers, toes, face or skull aren’t included in this measure.
Our Medicare Quality team will be working alongside you to close OMW care gaps by contacting members who still need to complete a BMD test to offer them education, guidance and support. For questions on HEDIS measure requirements, visit our 2024 HEDIS Provider Reference Guide.
Learn more about our fall quality initiatives
Throughout the year, our Quality team works alongside you to help close care gaps and improve health outcomes for our Medicare and Medicaid members. This fall, they’ll be conducting outreach to select members and providers for the following initiatives:
Helping your patients close care gaps from the comfort of home
- Let’s Get Checked (LGC)
The Let’s Get Checked campaign sends at home tests kits to your Priority Health Medicare and Medicaid patients in need of certain screenings to help close care gaps. This year, our Medicaid LGC initiative will focus on lead screenings, while our Medicare LGC initiative will focus on A1c and colorectal cancer screenings. - Exact Sciences
The Exact Sciences campaign also targets colorectal cancer screening care gaps. This program was piloted last year in addition to LGC’s colorectal cancer screenings to help gauge member participation in LGC’s annual testing versus Exact Science’s Cologuard® test, which is only needed every three years. What’s the difference between Exact Sciences and LGC colorectal cancer screenings?
Test
Description
Occurrence
Results
Exact Sciences Cologuard® test
This test screens for colon cancer and DNA markers that could indicate colon cancer.
A Cologuard test is needed once every 3 years.
Exact Sciences mails results directly to you and your patients. Your patients who test positive will also receive a phone call.
LGC fecal immunochemical test (FIT)
This test only screens for colon cancer.
An FIT test is needed annually.
LGC results are distributed to ACNs monthly by the Provider Strategy & Solutions (PSS) team. Your patients will receive results via mail, and those who test positive will also receive a phone call.
Patients who return their LGC or Exact Sciences test kits by December 31, 2024, will count toward providers’ 2024 PCP Incentive Program (PIP) participation.
OMW reports to help assess osteoporosis in your female Medicare patients
Beginning in September, we’ll be sending ACNs monthly reports to help close care gaps for the Osteoporosis Management in Women Who Had a Fracture (OMW) measure. The OMW measure helps identify and manage osteoporosis in your female Medicare patients who recently suffered a fracture.
Shaping our 2025 quality programs with our annual Patient care and coordination survey
Our 2024 Patient care and coordination survey kicks off in September. We’ll be contacting select providers via email to request your participation in a brief survey to help us better understand how you coordinate care for your patients, our members. The results of this survey allow us to tailor our 2025 Quality programs to the needs of our members and our providers. We encourage you to participate and share your feedback.
Supporting your Medicaid patients with HIV
Our Medicaid Quality team created a member education resource for your Priority Health Medicaid patients diagnosed with HIV. This resource will be sent to select providers via email and helps to educate patients on things like finding a provider, Priority Health care management services, transportation assistance and more.
Raising awareness of falls prevention
We’ll be emailing primary care providers to offer falls prevention resources and encourage them to join us September 23 - 27 in raising awareness for Falls Prevention Awareness Week, a nationwide health campaign that aims to decrease fall risks and improve the long-term health of patients through education and injury prevention. Learn more about our programs that support fall risk prevention.
Want more information on these campaigns and more?
Join us on August 29 at noon for our Q4 Quality campaigns VOA.