Priority Health: PriorityActions December 7, 2023 Issue

December 11, 2023

Dec. 7, 2023
Issue #1.4

Welcome to our biweekly PriorityActions for providers, where you’ll receive important information to help you work with us and care for our members.

You’re receiving this email because you’re a part of an Accountable Care Network (ACN) or Provider Organization (PO) with us. Please share relevant information with your provider groups and practices. Your Provider Strategy & Solutions consultant remains your primary contact for support.

requirements & responsibilities

2023 PriorityMedicare D-SNP Model of Care training is due Dec. 31

Who needs to complete training?

All providers who are part of the Priority Health Medicare Advantage network need to complete training. This includes specialists, ancillary providers, or anyone part of an ICT (interdisciplinary care team) for a D-SNP member. This is a CMS requirement.

How do providers complete the training?

Providers can complete our training using one of two options.

Option #1: Bulk attestations

You can group our D-SNP MOC training with existing, required training (like compliance training) so you can submit attestation for providers at the same time. If this option is selected, you’ll need to:

  1. Distribute training to your providers using this link.
  2. To attest to training, you must fill out the roster template with providers who’ve received training. If you choose to submit a provider roster, only the Priority Health MOC roster Excel sheet provided will be accepted.
  3. Send attestation rosters to

Option #2: Virtual training (only takes 15 minutes)

Training is available as an on-demand webinar and only takes 15 minutes for providers to complete. Online training can be accessed here. Provider registration for the on-demand webinar counts as attestation, which means no additional documentation is required.

Be sure to submit the correct provider NPI

Ensure the correct provider NPI number is included when submitting the provider roster or registering for the online training. If the NPI is incorrect, the provider’s status will be marked "incomplete" in our system. To correct an "incomplete" status due to an incorrect NPI, resubmit the provider roster or re-register for the online training with the correct provider NPI.

Your Provider Strategy & Solutions consultant will send you a report with providers who still need to complete training.

Haven’t attested with Better Doctor? You’ll get a call from Command Direct.

We’re working with Command Direct to reach out to providers who haven’t submitted their quarterly attestation through Better Doctor. These providers will receive a phone call from Command Direct, affiliated with Leap Orbit.

Accurate Find A Doctor listings are our goal

By attesting quarterly with Better Doctor, or through Command Direct’s follow-up process, providers ensure their listings in our Find A Doctor directory are up-to-date and accurate for members seeking in-network care. These attestations are separate from other attestations providers complete, such as CAQH.

Providers may be removed from our directory if, for example, their practice name doesn’t match the name used when answering the phone, or if other data, like location or hours of operation, are inaccurate.

Reduce your practices’ administrative work with batch attestations

ACNs have the option to submit batch attestation files for their practice groups to Better Doctor. This file can be in any format, as long as it includes the required information. For ACNs that submit these batch attestation files quarterly, their practice groups won’t be contacted by Better Doctor or Command Direct.

After submitting a batch attestation file, practice groups will receive an email noting any updates that may need to be made to their data with us. These updates must be submitted through prism or the delegation SharePoint site.

If your ACN is interested in batch attestations, contact Eileen Braxton at Better Doctor to get started.

November 2023 medical policy updates

Our Medical Advisory Committee (MAC), comprised of network physicians contracted with Priority Health, met in November and approved a series of medical policy updates.

Below is a summary of the updates, as shared in our Provider manual on Nov. 21:

Obstructive Sleep Apnea (91333)

  • Effective Dec. 18, 2023, the following testing and diagnostic services will be considered medically necessary when the applicable InterQual criteria are met (previously, Priority Health-specific medical criteria were applied):
    • Home sleep test or limited channel test
    • Facility-based polysomnogram
    • Facility-based titration study

Autologous Chondrocyte Implant / Meniscal Allograft / Osteochondral Replacement (91443)

  • Clarified medically necessary procedures for the knee versus other joints.
  • Added autologous cellular implant derived from adipose tissue, autologous adipose derived regenerative cell therapy or autologous micro-fragmented adipose injection (i.e., Lipogems) for any musculoskeletal indication are experimental and investigational.

Biofeedback (91002)

  • Clarification: Medicaid / Health Michigan Plan members directed to current Michigan Department of Health and Human Services (MDHHS) Medicaid. Non-coverage position for Medicaid remains unchanged.

Bone Density Studies (91494)

  • Added distal forearm DXA is medically necessary when criteria are met.

Cellular and Gene Therapy (91638)

  • Added guidance for Medicaid members.

Cingulotomy (91475)

  • Retired policy, created in 2004, as it has limited scope in current practice and low claims volume.

Colorectal Cancer Screening (91547)

  • Deleted items 1 through 6 under I.B. Advanced Screening and Evaluation Guidelines.
  • Updated reference provided in I.B. Advanced Screening and Evaluation Guidelines.

Computerized Tomographic Angiography Coronary Arteries (CCTA) (91614)

  • Fractional Flow Reserve Computed Tomography (FFR-CT) will be considered medically necessary when the applicable eviCore criteria are met (previously, Priority Health-specific medical criteria were applied).

Fecal Microbiota trans Fecal Bacteriotherapy (91603)

  • Clarified section II. Exclusions: Part C – removed the reference to RBX2660 and added a note directing the reader to the Priority Health Medical Benefit Drug List for coverage details for Rebyota™.

Gender Affirming Surgery (91612)

  • Added the following CPT codes to the table: 21172, 14041, 15769.

Osteoarthritis of the Knee (91571)

  • Added autologous chondrocyte implantation (i.e., Carticel) for the repair of articular cartilage of the knee is medically necessary.
  • Added genicular articular embolization for osteoarthritis of the knee is experimental and investigational.

Peripheral Nerve Stimulation (91634)

  • Added that ReActiv8® Implantable Neurostimulation System (Mainstay Medical Ltd.) is unproven and not medically necessary due to insufficient evidence of efficacy.

Surgical Treatment of Obesity (91595)

  • Clarified language around specifications of BMI ranges.

incentive programs

The Health Risk Assessment (HRA) incentive is retiring on Jan. 1, 2024

The Healthy Michigan Plan’s (HMP) Health Risk Assessment (HRA) incentive is retiring. Beginning Jan. 1, 2024, HRA completion will no longer be incentivized for our HMP members.

This only affects our HMP members. HRA completion for D-SNP members is still required.

Why is this incentive retiring?

The Michigan Department of Health & Human Services (MDHHS) will no longer require providers to complete an HRA for their patients effective Jan. 1, 2024.

Can I still complete and submit an HRA?

We encourage you to continue to complete and submit HRAs for your patients. The data we receive informs how we coordinate services available to our members, including identifying barriers to care, food and housing.

You can continue to submit HRAs using the following methods:

  • Via the Community Health Automated Medicaid Processing System (CHAMPS)
  • Fax it to us directly at 616.942.0616.

Beginning Jan. 1, 2024, the state fax line will no longer accept HRAs.

Will I still receive an incentive payment for HRAs completed in 2023?

Yes, incentive payments for HRAs completed through Dec. 31, 2023 will be paid according to the payment schedule below.

Thank you for your participation in this work and your commitment to the care and wellbeing of your patients, our members.

Final 2024 PIP manual is now available

The final 2024 PCP Incentive Program (PIP) manual (login required, see PCP Incentive Program) is now available. The following updates were made since the preliminary manual was released on Oct. 3:

2024 Program updates (pg. 5)

The Diabetes Care: HbA1c ≤ 9.0% (HBD) measure name has been updated to Glycemic Status Assessment for patients with Diabetes: HbA1c ≤ 9.0% (GSD), per HEDIS. See the 2024 HEDIS Provider Reference Guide (login required, see Quality Improvement) for more information.

Program measure grid (pg. 6)

The product payout and product targets have been finalized and are included in this final manual. The grid provides an overview of the incentive program, including the measure, product payout and product target.

PIP Hypertension & Diabetes reports clarified and now delivered weekly

To help you address open gaps in care as we approach the end of the 2023 performance year, you’ll now receive the following reports in Filemart weekly through January 2024:

  • PIP Hypertension Worksheet (PIP_11H): Identifies member level detail by PCP, by product, for members identified with Hypertension. Includes last blood pressure date, BP result value and source and last office visit date.
  • PIP Diabetes Lab Result Worksheet (PIP_11G): Identifies member level detail by PCP, by product, for members identified with diabetes. Includes last HbA1c lab date, value and source.

Additionally, we updated these reports with the following clarifications:

  • PIP_11H now reflects the message, “Enter a blood pressure value in supplemental data” only when we don’t have a most recent value identified.
  • PIP_11G now reflects the message, “Enter a lab result value in supplemental data” only when we don’t have a most recent lab value identified.

Get our 2024 HEDIS® provider reference guide

Our 2024 Healthcare Effectiveness and Data Information Set (HEDIS®) guide is now available. This guide serves to support you in your efforts to deliver quality health care to the communities we serve as well as your performance in our provider incentive programs.

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

It’s important to note that the HEDIS guide is a supplemental material and doesn’t replace our PCP Incentive Program (PIP) manual. You’ll continue to use our PIP manual as a reference for your participation in the program.


Norditropin coverage ending for commercial members effective Jan. 1, 2024

Due to severe shortages, Norditropin® coverage will end for our commercial group and individual members on Dec. 31, 2023. This includes both new-start and existing prescriptions.

Norditropin will remain on the Medicare formulary, with prior authorization requirements, through 2024.

Effective Jan. 1, 2024, Omnitrope®, an HGH drug, will be added to formulary as a tier 4 drug with prior authorization requirements.

How will this impact you?

Beginning Jan. 1, 2024, you’ll need to write impacted members a new prescription for either Genotropin or Omnitrope and send it to an in-network specialty pharmacy.

To assist you with this transition, prior authorizations for Genotropin and Omnitrope have been added for members with current authorizations on file for Norditropin.

For new starts on Genotropin or Omnitrope, prior authorization is required.

How are we communicating this to members?

Impacted members will receive a letter advising them of their drug coverage changes and what steps they can take prior to Jan. 1, 2024.

To avoid interruptions in their care, members have been encouraged to speak with their providers about whether transitioning to Genotropin or Omnitrope is right for them.

You’ll receive a follow-up communication from your Provider Strategy & Solutions consultant with member impact reports.

Thank you for partnering with us in our commitment to providing the best possible treatment options for your patients, our members.

plans and benefits

The Vaccines for Children program offers government purchased vaccines to eligible members

Did you know the Vaccines for Children (VFC) program offers government-purchased vaccines to eligible members at no cost to you?

What is the VFC program?

The Vaccines for Children (VFC) program is a federally funded program that provides vaccines at no cost for Medicaid-eligible infants, children and adolescents up through age 18.

The Centers for Disease Control (CDC) acquires vaccines at a discounted rate, making them available at no cost to participating physicians' offices and public health clinics.

How can the VFC program help you in your practice?

With the VFC program, you can administer all pediatric and adolescent age-appropriate preventive vaccines (or CDC age-appropriate recommended vaccines) at no cost to you, while still receiving reimbursement for administration costs. This can also help improve vaccination rates and increase your performance in our PCP Incentive programs.

How do you bill for a VFC visit?

The state Medicaid agency should be billed for the administration fee for Medicaid-eligible VFC children immunized by a Medicaid-enrolled VFC provider. You can find more information in the VFC Provider Manual (page 20).

How can you enroll in the VFC program?

Find information on enrollment, vaccine storage and administration, and other VFC program details from the Michigan Department of Health and Human Services.

Keep an eye out for our VFC survey.

PCP participation is crucial to VFC’s ongoing success. We’ll be sending out a survey to better understand your relationship to the VFC program and how we can best support you.

Contact your Provider Strategy and Solutions consultant if you’re having trouble with enrollment or if you have additional questions.

training opportunities

Join us for our next Virtual Office Advisory (VOA) on Dec. 14

Join us for our next Virtual Office Advisory webinar at noon on Dec. 14 and learn about:

  • prism security: The pSA (prism Security Administrator) process for TPAs (third-party administrators), how practices can determine if their affiliation has a pSA and how to assign pSAs in prism.
  • Pharmacy updates: Formulary changes, coverage changes for Humira and its biosimilars, RSV vaccine coverage updates, pharmacy specialty network updates and continuous glucose monitor core benefit changes.
  • Medicaid Quality updates: Information on pre-exposure prophylaxis, chronic kidney disease, doulas and lead screenings in children.
  • prism inquiry tips: Submitting inquiries using the Clinical Edits dropdown vs. the Other Related Claims dropdown in prism and submitting inquiries for issues impacting more than 10 claims.

How to register

You and your providers can join us by registering online.

Can’t join us?

All VOAs are recorded and posted to our website within a week of the webinar, so you can watch at your convenience.