Priority Health has provided the latest Priority Actions Update as of August 8, 2024. Below is a recap of information offices should be aware of:
PLANS AND BENEFITS
Medicaid rebid impacts on providers in Northern and Southwest Michigan
The first Medicaid rebid since 2015 was just finalized, and the results will impact your work with Priority Health Medicaid members if you’re a provider in Northern or Southwest Michigan. The changes take effect on October 1.
What's the Medicaid rebid?
The Medicaid rebid is a competitive process run by the Michigan Department of Health and Human Services (MDHHS) which determines where health plans can offer their Medicaid products in Michigan. Michigan is divided into 10 “Prosperity Regions,” each of which allows one or more health plans to serve the Medicaid members living there.
The rebid changes take effect on Oct. 1, 2024. They'll be in effect until the next rebid, which will not occur until at least 2029.
Members will be receiving an MDHHS letter with information if their current plan is exiting the region they live in. They’ll then be given a chance to choose a new plan online by September 17, or they’ll be automatically assigned to one of the new plans entering the region.
What’s changing for Priority Health?
As a result of the rebid, Priority Health maintained access to Regions 4 (West Michigan) and 10 (Detroit Metro), gained access to Regions 2 and 3 (Northern Michigan) and lost access to Region 8 (Southwest Michigan). See below for a list of the counties in the regions that we’re entering and leaving and what you need to know if you’re a provider in these regions.
Regions 2 and 3
(Northern Michigan)
Welcome to our Medicaid network. If you’ve been in the health care industry since 2015, you’ll remember that we’ve served Medicaid members in your region before, and we’re excited to be back.
If you’re not yet in our network, please join. If you’d like to begin serving Medicaid members and haven’t yet been credentialed to do so, please visit MDHHS’s Community Health Automated Medicaid Process System (CHAMPS) page.
Counties in Regions 2 and 3
- Alcona
- Alpena
- Antrim
- Benzie
- Charlevoix
- Cheboygan
- Crawford
- Emmet
- Grand Traverse
- Iosco
- Kalkaska
- Leelanau
- Manistee
- Missaukee
- Montmorency
- Ogemaw
- Oscoda
- Otsego
- Presque Isle
- Roscommon
- Wexford
As long as you’re in our network, you can continue to see the Medicaid members you’ve been seeing if they transition to our plan. If you’re the member’s PCP, encourage them to name you as their assigned PCP during the transition period or to use their member portal after October 1 to select you as their PCP.
If you have patients choosing a plan, we encourage you to share this informative MDHHS guide to Michigan Medicaid health plans, which provides quality ratings in a variety of categories for each Michigan Medicaid health plan and shows Priority Health as the highest ranked plan in the lower peninsula. For more information about Priority Health Medicaid specifically, you can direct your patients to our Michigan Medicaid page.
We have several resources in our provider manual for you to refer to and bookmark as you work with our Medicaid members:
- Priority Health Medicaid program info
- Medicaid patient treatment requirements
- Priority Health’s downloadable Medicaid Provider Manual
You can also find general information about being a Medicaid provider in Michigan on MDHHS’s site for Medicaid providers.
Regions 8 (Southwest Michigan)
Thank you so much for having served our Medicaid members so well these past several years.
Encourage your members to refer to their MDHHS letter for information about changing plans. If they don’t pick a new plan by September 17, they’ll be automatically assigned to one of the new plans in the region. Neither you nor the member need to do anything to end their Priority Health Medicaid coverage on October 1.
Counties in Region 8
- Berrien
- Branch
- Calhoun
- Cass
- Kalamazoo
- St. Joseph
- Van Buren
Still have questions?
See our provider FAQs for more details about the rebid and its impacts.
REQUIREMENTS AND RESPONSIBILITIES
Starting September 23, groups must have a pSA to affiliate prism users
Starting September 23, prism users will only be able to affiliate to groups or facilities that have a pSA. If the group doesn’t have a pSA, users will not be able to access the group’s data until the group assigns a pSA. This means users won’t be able to use prism to submit authorizations, see claims or appeals, etc.
What do you need to do?
If you don’t have a pSA assigned for your group, you’ll need to assign one before September 23 to ensure all prism users who need to affiliate to your provider facility can get access to authorizations, claims and more.
To become your group's pSA, submit a request through prism under General Requests, then prism Security Admin (pSA) Assignment. Whoever becomes your group’s pSA should be a prism user who’s already affiliated to your group and in an administrator role at your organization.
If your group already has a pSA assigned, no action is needed.
Why are we making this change?
This change is the first phase of our pSA mandate, an important step to increase data security for our providers and members. By ensuring that all prism users are actively approved before accessing your group’s data, rather than automatically approved, we’re significantly decreasing the risk of data breaches.
Why are we making this change?
Later in 2024, the second phase of our pSA mandate will take effect. Existing prism users affiliated with your group will lose access to your group in their prism account if you don’t have a pSA assigned. If you have a pSA assigned, you’re all set.
Don’t know if you have a pSA assigned?
- Go to your prism profile and find your list of affiliations.
- Scroll to the far right of the table and select “Show pSA details.” If you don’t have this option, a pSA hasn’t been assigned to this affiliation.
- You can contact the pSA assigned to each affiliation to confirm your access will be renewed, but it’s not required.
What’s next?
Later in 2024, the second phase of our pSA mandate will take effect. Existing prism users affiliated with your group will lose access to your group in their prism account if you don’t have a pSA assigned. If you have a pSA assigned, you’re all set.
Questions?
Visit the prism resources page in our provider manual, where there are guides, FAQs and help line numbers listed.
Reminder: You must complete our 15-minute CMS-required D-SNP Model of Care training
Providers play an integral role in the care teams that support our dual-eligible special needs (D-SNP) members. That's why the Centers for Medicare and Medicaid Services (CMS) requires us to make sure providers who are contracted with us to see PriorityMedicare patients are trained on our Model of Care.
Our Model of Care is a quality improvement tool that ensures the unique needs of our D-SNP members are met and describes the processes and systems we use to coordinate their care.
Who needs to complete Model of Care training?
- All providers who are part of the Priority Health Medicare Advantage network
- Out-of-network providers who see at least five D-SNP members
This includes specialists, ancillary providers and anyone part of an ICT (interdisciplinary care team) for a D-SNP member. This is a CMS requirement.
Your Provider Strategy & Solutions Consultant will reach out to you with a report of providers who need to complete training and/or a report of providers who entered an incorrect NPI and need to re-attest to training.
How to access training
You can choose to group our training with any existing, required training (like compliance training) or use our 15-minute on-demand webinar.
Refer to our Provider Manual for details on how to complete training.
Training needs to be completed and attested to by Dec. 31, 2024. Late submissions will not be accepted.
INCENTIVE PROGRAMS
APCD replacement files will be delivered via SFTP starting August 15
As we noted in late 2023, we’re in the process of retiring our All Payer Claims Database (APCD) files and transitioning to the new, more robust Provider Group Extract (PGE) files.
We’re happy to share that the PGE files are ready to send out. ACNs currently receiving APCD will begin receiving PGE via Secure File Transfer Protocol (SFTP) on the 15th of each month, starting August 15.
If you’re not yet set up to accept SFTP files from us, or if you’re not receiving APCD but would like to get started with PGE, please contact your Provider Strategy & Solutions Consultant.
ACNs currently receiving APCD files will continue to receive them through the end of 2024.
Why are we making this change?
The APCD is being updated as historical APCD logic didn’t align with Priority Health cost, use or quality reporting which at times could result in variance between reports. The revised PGE files use the same logic and data source representing a true raw claims feed so you can better monitor and understand the population you serve.
What will be included in PGE?
Like the APCD, the PGE will reflect all medical and pharmacy claims. An eligibility feed / membership roster will also be provided.
Our PGE data dictionary (access from our FAQ linked below) will help you compare what you receive today through APCD with what you’ll receive with PGE. This Excel spreadsheet lists the fields appearing in each extract with a data description, type, size and format.
Get more information
For additional details, see our PGE FAQ.
AUTHORIZATIONS
Resources & trainings for TurningPoint authorizations programs
New cardiology and MSK authorization programs are set to launch with TurningPoint for dates of service on Sept. 1, 2024 and after. Starting August 20, your providers will have the opportunity to test the new authorizations submission process. They’ll initiate authorization request in our provider portal, prism, as they do now. These requests will then be routed to TurningPoint for review.
Procedures requested for dates of service on and after September 1 will be reviewed against TurningPoint’s clinical criteria. Providers will be able to find this criteria in TurningPoint’s portal under the Policies section starting on August 20.
We’ve prepared several training resources and opportunities to help your providers be successful through this transition. See below for details.
Provider training guide
Download our TurningPoint provider training guide to get an overview of the scope, features and operational process of the cardiac and MSK managed care programs. In the training guide, you’ll find:
- Background information on the programs
- Step-by-step instructions for submitting authorization requests for cardiac and MSK procedures, with detailed screenshots
- Instructions on how to update a procedure code, status an authorization, request a peer-to-peer and submit an appeal
- Contact information, customer service and ongoing support details
Web landing page
Visit our new TurningPoint resources webpage which includes FAQs, impacted procedure codes, turnaround times, peer-to-peer and 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.
Training webinars
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 now available for the following dates, with each session starting at 12 p.m. ET:
- August 14
- August 21
- August 28
- September 4
Can’t make it during the webinar’s scheduled time? A recording of the session will be sent to all registrants for on-demand viewing.
Outreach to high-volume providers
TurningPoint has begun reaching out directly to high-volume cardiac and MSK provider offices. They’re offering these providers the option to meet one-on-one with their provider relations and medical teams, either virtually or in person, to:
- Support training and education in the lead up to the programs’ launch
- Answer any outstanding questions
- Build a relationship for two-way communication and feedback
Provider trainings for EviCore’s radiation oncology authorizations program
Join EviCore to learn about the new radiation oncology authorization program set to launch this September, as well as how to navigate and successfully request authorizations through EviCore.
Registration is now available for the following dates / times:
- Sept. 3, 2024 @ 1 p.m. ET
- Sept. 5, 2024 @ 11 a.m. ET
- Sept. 10, 2024 @ 1 p.m. ET
- Sept. 17, 2024 @ 1 p.m. ET
To register:
- Go to evicore.webex.com.
- Select WebEx Training from the menu bar on the left.
- Click the Upcoming tab and choose the desired session. You can enter Priority Health into the search bar to filter our sessions.
- Click Register next to the chosen session.
- Enter the registration information.
A copy of the presentation will be made available online at evicore.com/resources/healthplan/priority-health for those unable to attend live.
Finalizing 2024 InterQual® criteria transition
As we announced in May, we updated our authorization tools to 2024 InterQual® criteria on July 15 for the following authorization types:
- Level of care (LOC): Inpatient Rehabilitation
- LOC: Subacute/Skilled nursing facility
- LOC: Home Care Q&A
- LOC: Long-Term Acute Care
- CP: Durable Medical Equipment
- CP: Procedures
- Medicare: Post Acute & Durable Medical Equipment
- Medicare: Procedures
- Behavioral health (BH): Adult and Geriatric Psychiatry
- BH: Child and Adolescent Psychiatry
- BH: Substance Use Disorders
- BH: Services
There was a slight delay in updating two authorization types – Acute Adult and Acute Pediatric – which will transition to 2024 InterQual criteria effective August 5.
BILLING AND PAYMENT
New coding policies posted to the Provider Manual
We recently posted the following policies to our Provider Manual. Below are links and a high-level overview of each policy. Please see each policy for specific billing, coding and reimbursement details.
- Background: This policy provides industry standard billing guidance to support correct billing. It includes the applicable medical policy which providers can reference for prior authorization requirements, whether the exact lab test name is required on the claim and documentation requirements that are standard for lab testing.
- Applies to: All plans
- Effective: N/A, providing transparency around existing requirements / expectations
- Description: This policy describes the reimbursement methodology for lab and lab-related services. It outlines billing guidelines for place of services, duplicates, multiple tests per day and diagnosis coding.
- Applies to: All plans
- Effective: N/A, providing transparency around existing requirements / expectations
Cardiology: Pacemakers coding policy
- Description: This policy provides industry standard coding information to support correct billing for single, dual and leadless pacemakers. It provides procedure definitions, shares specific modifiers and place of service codes and instructs providers on when a pre-service organization determination (PSOD) is needed for Medicare members.
- Applies to: Commercial and Medicare plans (for Medicaid, providers should reference the Medicaid Provider Manual)
- Effective: N/A, providing transparency around existing requirements / expectations