Priority Health - PriorityActions May 9, 2024 Issue

May 13, 2024

Change Healthcare outage update: Electronic RAs resumed through Change Healthcare and Optum clearinghouses; all services should be restored

-Electronic remittance advices turned back on this week 
If you’re set up to receive electronic remittance advices (ERAs) through Change Healthcare or Optum, you should have received files from February, March and April starting the week of April 29. 

-All services restored; contact your clearinghouse if you’re not able to submit claims 
Claims we receive continue to process as normal. We’re receiving claims from all clearinghouses we work with. If you’re still having issues submitting claims, contact your clearinghouse. 

-Paper checks 
Paper checks and paper remittance advices continue to send through a manual process. Please keep your check stubs so you’re able to match the check reference ID number to your RA when it arrives separately in the mail. 

-Change Healthcare communications archive 
Visit the News & education page in our Provider Manual for an archive of communications we've sent about the Change Healthcare outage. 


We’re transitioning to 2024 InterQual® criteria starting July 15

We’re aligning to nationally recognized standards to ensure our members are getting the right care, in the right place, at the right time by updating to 2024 InterQual® on July 15, 2024. 

-Why are we updating to 2024 InterQual? 
InterQual is nationally recognized as an industry standard for evidence-based medicine criteria, ensuring appropriate care. These criteria are regularly updated to reflect the most recent evidence-based and clinical standards. 

-What authorization types are affected? 
As a result of this transition, the following authorization types will be based on modifications to 2024 InterQual criteria: 

  • Level of care (LOC): Acute Adult*
  • LOC: Acute Pediatric*
  • 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

*Several criteria set revisions based on best practices and available evidence 



We’re no longer allowing providers to be enrolled under multiple ACN contracts with the same NPI, TIN and address

Effective July 8, 2024, we’ll no longer allow providers to be enrolled under more than one ACN contract at a time under the same NPI, TIN and address. This includes ACNs with both direct and delegated contracts. 

ACNs enroll their providers with Priority Health through prism (direct) or through a SharePoint submission process (delegated). If an ACN is requesting to enroll a provider that's still enrolled with another ACN, we have been leaving the provider enrolled under the original ACN’s contract, adding the new ACN enrollment as an alternate and sending a letter to request the provider update their enrollment with us. 

For example: Dr. Jane Smith is an in-network provider, enrolled with Beaumont ACO. OSP submits an enrollment request in prism for Dr. Jane Smith using the same NPI, TIN and address as her current enrollment. In our system, Dr. Smith is now enrolled under both Beaumont ACO and OSP, Beaumont being primary, and our teams send a letter directly to Dr. Smith to determine which group is primary. 

-What’s going to change on July 8? 
On July 8, 2024, our system will automatically update to enroll providers under the contract of ACN that last requested them. 

Continuing from the example above: Dr. Jane Smith is enrolled under Beaumont ACO and OSP. On July 8, Dr. Smith will only be enrolled under OSP.

-Why we’re making this change 
Allowing providers to be enrolled under multiple ACN contracts using the same NPI, TIN and address has led to: 

  • Pricing issues as the provider is enrolled under multiple ACNs 
  • Inaccurate reporting as we are unable to pull accurate rosters for providers if their ACN isn’t accurate in our system
  • PRA issues because of inaccurate ACN listings

-Member impact 
If a member had been covered at in-network or first-tier levels with a provider solely because of that provider’s previous enrollment status, they may no longer be covered at those levels at this provider after this change. This should only be an issue with narrow network and tiered network plans, and as long as members are seeing providers who meet specific network inclusion criteria, it won’t be an issue. 

-What else do PHOs / POs need to know? 
The provider will not be notified of a change to their enrollment via letter or email. If they would rather be enrolled under the contract of a previous ACN, they should reach out to that ACN to have them resubmit an enrollment request or open a prism inquiry. 

This update won’t impact the data stored in our Provider Roster Application (PRA) tool. ACNs will still need to negotiate the provider in question’s release from their current ACN for value-based program roster management. 

For assistance with this, ACNs should reach out to their PSS Consultant. 


We’re requesting medical records for an MDHHS audit

Our Encounter Data team is reaching out to a small number of providers selected randomly by the state to request medical records for the Michigan Department of Health and Human Services (MDHHS) Encounter Data Validation (EDV) audit. 

-Why are we requesting medical records? 
MDHHS is reviewing medical records to evaluate encounter data for completeness and accuracy. 

-How are we contacting providers?
We’ll send you an email if we have an email address on file for your practice, otherwise we’ll call or mail letters. 

-What you need to do
If you’re contacted by our Encounter Data team, please send all requested documentation via fax, mail or secure email by May 31, 2024

-How to send us documentation
Medical records can be securely sent to Priority Health by: 

  • SharePoint electronic upload: Email for access
  • Email: Send us a secure email to 
  • Fax: 616.464.8905, attention: Becki Denick
  • Mail: Priority Health 1239 East Beltline Ave NE, Grand Rapids MI, 49525; Mail Stop 1250; Attention: Becki Denick

-Have questions? 
If you have questions, please contact our Encounter Data team at  



We’re reprocessing incorrectly rejected Tdap vaccine claims

Between July to September 2023, claims for CPT code 90715 (Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or older, for intramuscular use) front-end rejected for missing National Drug Code (NDC) when they shouldn’t have. 

There’s nothing you need to do. . These claims were billed correctly, and we’ll reprocess them for payment. Your 2023 PCP Incentive Program (PIP) settlement won’t be impacted as immunization data is pulled from MCIR, not claims. 

We value your partnership and the care you provide our members. We sincerely apologize for any inconvenience this has caused. Thank you for your patience and understanding.