Priority Health: PriorityActions Issue November 2, 2023

November 6, 2023

Nov. 2, 2023
Issue #1.2

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


Commercial and Medicare formulary updates coming Jan. 1, 2024

In January and July of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial and Medicare formularies to ensure our members have access to safe, effective and affordable drugs.

Commercial changes effective Jan. 1, 2024

Starting Jan. 1, 2024, 53 commercial drug changes impacting 14,166 members will go into effect. These changes will either remove a drug from the formulary, increase the tier the drug is in or add prior authorization to a drug.

Medicare changes effective January 1, 2024

Starting Jan. 1, 2024, 50 Medicare drug changes impacting 5,738 members will go into effect. We’ve made the following enhancements to the Medicare formulary, positively impacting thousands of our members:

Formulary changes

The following drug changes take effect Jan. 1, 2024, and will either add a prior authorization requirement if a diagnosis is not on file, remove the drug from formulary or increase the tier the drug is in.

Pharmacy network update

Commercial/individual pharmacy updates

  • Meijer Specialty Pharmacy will no longer be a participating network specialty pharmacy for commercial and individual members beginning Jan. 1, 2024. Find more information here.

Medicare pharmacy updates

  • Kroger pharmacy will no longer be a participating network pharmacy for Medicare members effective Jan. 1, 2024.
  • Orsini Specialty Pharmacy will no longer be a participating network specialty pharmacy for Medicare members effective Jan. 1, 2024. Providers are encouraged to submit new prescriptions to our in-network specialty pharmacies, Accredo or Corewell Health Specialty Pharmacy.

How we’re communicating to members

Members impacted by changes will receive a letter advising them of their drug coverage changes, what steps they can take prior to Jan. 1, 2024, and what alternative medications are available to them.

Your Provider Strategy & Solutions consultant will send you a list of impacted members so you can review and proactively recommend alternatives to your patients. Your patients may also contact you, after receiving their letter, seeking alternative options.

If you’d like to hear more about our 2024 formulary changes, join us Dec. 14 at our Virtual Office Advisory to ask questions and learn more.

plans and benefits

Our first annual Medicaid Let’s Get Checked campaign kicked off Oct. 18

Our first annual Medicaid campaign to close gaps in care, in partnership with Let's Get Checked (a Let’s Get Checked company) kicked off on October 18, 2023. This year’s campaign targets our members, your patients, who have a gap in care for: 

  • Lead Screening (Medicaid Only) 
  • HbA1c Screening (Hemoglobin A1C test) 

Your patients who return their test kits to Let’s Get Checked by December 31 will count towards your 2023 PCP Incentive Program (PIP) participation. See the attachments for the Let’s Get Checked Provider Guide and an initial list of your patients who will receive a welcome letter and the appropriate test kits.

Campaign information

If applicable, you’ll receive follow-up information from your Provider Services and Solutions consultant with a targeted patient list as well as the Let’s Get Checked provider guide which includes:

  • More information regarding the clinical components of each test 
  • Examples of kit materials 
  • An outline of the member and provider result notification process

Both patients and their attributed PCPs will receive results for each returned kit. Patients will receive results via mail, and those with positive results will also receive a phone call from the Let's Get Checked outreach team. We’ll also send you kit results to distribute to your practice groups on a weekly basis throughout the campaign.

You’ll receive a secure email from your Provider Strategy & Solutions consultant with a list of patients who received a welcome letter and test kits.

Expanded price transparency with our Cost Estimator tool

The way people shop for health care continues to change. Consumers are looking for cost transparency and want to know what they are paying for, the same as if they were shopping for a new car or appliance.

To meet this consumer demand and to meet new government regulations, we’ll begin providing price and cost-sharing information for all covered procedures and services on January 1, 2024, to group and individual commercial members and providers through our Cost Estimator tool in partnership with Healthcare Bluebook. Cost Estimator will still be known by the same name.

Why are we making this change?

On October 29, 2020, the Departments of Health and Human Services (HHS), Treasury and Labor issued the “transparency in coverage” final rule. The rule imposes new transparency requirements on most group health plans and health insurers in the individual and group markets. The purpose of the requirements is to enable consumers to make informed health care purchasing decisions.

The final rule requires health plans to disclose prices and cost-sharing information for all covered services, including all encounters, procedures, medical tests, supplies, durable medical equipment and fees (including facility fees).

Pricing for medications or other pharmacy benefits will not be included in this change.

What exactly is changing?

We’ve been a leader in the cost transparency space since 2014, when we originally launched the Cost Estimator tool. So this won’t be as much a fundamental shift as just an expansion of what we’ve already been doing.

It should be noted that the methodology for calculating a cost estimate is changing. Now, an estimate will be produced using allowed amounts from aggregated claims data. This may result in prices being estimated differently than they previously were.

What is the impact to the Priority Health network?

The new version of the Cost Estimator tool helps members avoid billing surprises by seeing costs ahead of time. Fewer billing surprises means fewer unhappy patients.

As with all procedures and services having cost estimates, you may also receive questions from patients about costs or experience the effects of patients shopping for lower costs. We believe that competition is a net positive and a key driver of care affordability.

Can providers still access Cost Estimator?

Yes, you’ll continue to be able to access Cost Estimator via prism, where you’ll be able to see what your patients see and what their out-of-pocket costs are for services. More details will be coming in early 2024 about how to use the updated provider version of the Cost Estimator tool.

billing and payment

HCC coding shifting to the V28 model starting Jan. 1, 2024

The Centers for Medicare and Medicaid Services (CMS) is phasing in the V28 model for risk adjustment to replace the V24 model for risk adjustment beginning Jan. 1, 2024. The new model has significant changes to HCC coding and diagnosis mapping.

What’s changing?

Below are highlights of the new V28 model for risk adjustment:

  • The number of HCC categories increased from 86 to 115, and categories were renumbered
  • Changes were made to diabetes coding, a very commonly reported condition
  • Some diagnoses were removed entirely

Why is this important?

Coding accuracy and specificity are essential to capturing a patient’s full burden of illness, ensuring care management programs are offered to the right members and closing gaps in care.

For those participating in an alternative payment model (APM), reimbursement rates have the potential to change due to weight changes for some hierarchal condition categories (HCCs).

Learn how to be successful with the new coding requirements

We’re here to help. Register below for our upcoming webinar, “Understanding HCC coding: an introduction to the new V28 model for risk adjustment” for a comparison of the V24 and V28 models for risk adjustment and an overview of key changes, how these new requirements will impact you and how you can be successful.

Register here:

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. We strongly encourage you to take our training online, as this is the easiest and most efficient way to attest training.

However, if you know that your group already conducts Model of Care training that includes other payors and has a preferred method of delivering training to their providers, you can communicate the option that fits best into their existing process. Otherwise, you can share both options.

Option 1: (Recommended option) Training is available as an on-demand webinar and only takes 15 minutes for providers to complete. Online training can be accessed here. This link can be sent to ACNs to distribute to their practices. Feel free to use the provided Outlook template with this information. Provider registration for the on-demand webinar will count as attestation since we’re able to pull reporting on the tool, which means no additional documentation is required.

Option 2: Training can be sent directly to the ACN in the form of a presentation deck. The ACN can distribute this deck to their providers in their preferred format. This option works best if your ACN has other provider training obligations, like compliance training, that they would like to offer to providers at the same time. If this option is selected, your ACN will need to:

  • Distribute training to their providers.
  • To attest to training, ACNs and practices must fill out the roster template with providers who’ve received training. If they choose to submit a provider roster, only the Priority Health MOC roster Excel sheet provided will be accepted.

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.


Please send attestation rosters to

Your Provider Strategy & Solutions consultant will send a Tableau report with providers who still need to complete training, a provider roster template and the presentation deck via secure email.

incentive programs

Get our updated 2023 PIP Manual

We recently updated our 2023 PCP Incentive Program (PIP) manual.

Download the 2023 PIP Manual

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Here’s a summary of the changes:

Care Management (pg. 18)

  • Clarified that if a PCP retires or leaves the network, those touchpoints won’t count

Social Determinants of Health (pg. 20)

  • Added new z-codes, and a new rev code
  • Fixed CPT code typos

Appendix 7: Appropriate statin use in diabetic patients (pg. 43)

  • Added appendix to clarify and outline the SUPD Medicare 5 Star measure specifications, including tips on being successful in this measure

Appendix 8: Medication adherence in patients with diabetes, hypertension and high cholesterol (pg. 46)

  • Added appendix to provide tips on being successful in these measures

Patient discharge moves to Member Inquiry tool as Patient Profile retires

In January 2024, our online patient discharge tool will move from Patient Profile into prism’s Member Inquiry tool. This change comes as Patient Profile is set to be removed from prism on February 1 as part of our Digital First data strategy.

Any patient discharges submitted through Patient Profile after the new tool’s launch won’t be processed.

In the coming weeks, we’ll share the exact implementation date and step-by-step instructions for submitting patient discharges.

PCMH designations are now in Find A Doc

PCPs’ Patient Centered Medical Home (PCMH) designations are now available in our Find A Doc tool. This addition will help our members find quality, in-network care near them.

What is PCMH?

PCMH is a model of care that puts patients at the forefront of care. PCMHs build better relationships between patients and their clinical care teams, transforming the way primary care is organized and delivered.

Practices that earn this designation have made a commitment to care that is comprehensive, patient-centered, coordinated, accessible and quality.

Where can FAD users see PCMH designation?

The PCMH designation logo (below) is visible on applicable PCP profiles, on the PCP’s primary address only. Alternative addresses won’t reflect the designation.

What is PCMH?

PCMH designation is part of your monthly PRA attestation process. We’ll update Find A Doc annually using the November PRA attestation.