News

Thank you to those of you who could join us on the evening of October 25 for the BCN/BCNA/MAPPO Gain Share Contract and Program updates for 2024. We know some of you had conflicts and were not able to attend, so we recorded the meeting. Due to the size of the file, we are pushing the recording of that meeting through your EDIFECS accounts tomorrow. It sometimes takes several hours for those to go through, so I’d give it until Wednesday to retrieve it.   

Review this important information to help you work with Priority Health and care for members.

Blue Care Network mailed additional letters in October 2023, to primary care physicians and prescribers with BCN patients who are being offered the opportunity to receive a pharmacogenomics, or PGx, test as part of BCN’s new Blue Cross Personalized MedicineSM program.

One or more of your physicians is included in this additional mailing. Attached is a generic copy of the letter mailed. In addition, each physician received a list of his or her patients being offered the test, a Quick Start Guide and a copy of the member communication (also attached).

Priority Health has updated our observation stays policy to align with industry standards. Observation stays will now be reimbursed up to a maximum of 72 hours, across all plan types. Stays exceeding 72 hours will not be reimbursed.

This change aligns with CMS policy which defines observation stays exceeding 72 hours as medically unlikely. It will also support our shared goal of ensuring our members, your patients, get the right care in the right setting.

Thank you all who joined us at the Hilton Garden Inn for our annual payor conference.  It was so much fun to get together again and see our friends in person! We hope you found our conference helpful and, as promised, below are the presentations by our payor partners:

Beginning Jan. 1, 2024, Meijer Specialty Pharmacy has chosen to no longer participate in our specialty pharmacy network for commercial and individual members. This change only impacts drugs covered under the pharmacy benefit. Drugs covered under the medical benefit aren’t affected.

Medicare and Medicaid members can continue to use Meijer Specialty and retail pharmacies for all their prescriptions. All members may continue to use Meijer’s retail pharmacies for their prescriptions that don’t require a fill at a network specialty pharmacy.

Beginning Oct. 19, you’ll receive biweekly PriorityActions emails that will include important and actionable information to help you work with us and care for our members, your patients.

To maintain our commitment to providing our members with the most effective therapies at the lowest possible cost, Humira coverage will end for our commercial group and individual members on Dec. 31, 2023. This includes both new-start and existing prescriptions.

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

Effective Oct. 1, 2023, coverage for the Humira biosimilars, Hadlima and Adalimumab-adaz (manufactured by Sandoz) was added to our Medicare, commercial and individual member formularies.

We know how much hard work you put into population health and chronic condition management in your practices. We want to make capturing important information about your patients easier and more efficient so you can focus your time on what matters most – your patients, our members.

The Lakeland Medical Office Association invites you and/or your staff to attend our October luncheon and half-day meeting, sponsored by the Lakeland Care Network.

Program: Lakeland Care Network’s Annual Payor Conference

This year’s Payor Conference will feature the major payors in our market – including those who have Commercial, Medicare, Medicaid and Dual-eligible products.  Lakeland Care will also provide an update on our network's current projects and future initiatives.

Blue Care Network mailed additional letters in September 2023, to primary care physicians and prescribers with BCN patients who are being offered the opportunity to receive a pharmacogenomics, or PGx, test as part of BCN’s new Blue Cross Personalized MedicineSM program.

One or more of your physicians is included in this additional mailing. Attached is a generic copy of the letter mailed. In addition, each physician received a list of his or her patients being offered the test, a Quick Start Guide and a copy of the member communication (also attached).

Priority Health has provided an update to a popular handout with highlights of typical office questions that Priority Health receives. Please feel free to print and share with your office teammates!

Please see the attachment provided below for all of the details. 

The Centers for Disease Control and Prevention recommends a yearly flu vaccine for everyone ages six months and older as the best protection from this serious illness. Lakeland Care Network (Lakeland Care), in collaboration with Corewell Health, will offer drive-through community flu shots on the following dates:

As healthcare continues to transition into the digital space, we’re adapting our data strategy to follow suit. 

We announced in June that Patient Profile and the PIP_70 report will be retired with the close of the 2023 PIP performance year. Beginning with the 2024 performance year, we’ll accept only the following supplemental data sources for quality gap closure: 

Blue Cross Blue Shield of Michigan has experienced a work stoppage with our UAW-represented workforce. While we work to reach a labor agreement, please be assured that we will continue to process and pay your healthcare claims.

Your provider offices should continue to submit claims as normal. We will process and reimburse healthcare practitioners throughout the work stoppage. All of our benefits and billing requirements remain the same.

As of July 1, 2023, the State of Michigan is now covering diabetes prevention program (DPP) participation for Medicaid enrollees statewide. This means that more than 18,000 eligible Priority Health Medicaid members may now participate in this important, free lifestyle change program.

A summary of the September news and talking points from UnitedHealthcare.

Our Medical Advisory Committee (MAC), comprised of network physicians contracted with Priority Health, met this month and approved a series of medical policy updates. All updates are outlined in our policy updates webpage; below is a new policy we want to draw your attention to.

Effective Jan. 1, 2024, Tezspire® coverage will shift from a medical benefit to a pharmacy benefit for commercial and individual lines of business.

Blue Care Network mailed additional letters in August 2023, to primary care physicians and prescribers with BCN patients who are being offered the opportunity to receive a pharmacogenomics, or PGx, test as part of BCN’s new Blue Cross Personalized MedicineSM program.

Lakeland Care Network offices have just today been notified of upcoming changes that will affect new credentialing applications this last quarter of 2023. This is due to new credentialing software implementation being implemented in late September 2023. Please read below the statement from the Corewell Health Medical Staff Office.

Access the latest literature from Community Plan for provider offices caring for UHC-CP members.

In response to provider requests, we’re updating how we pay PCPs for behavioral health collaborative care (BHCC) services and care management telephone management services.

Humana announced this morning that effective October 1, 2023, they no longer will be quoting their Commercial product in Michigan.

UnitedHealthcare has shared its July 2023 Network News with all of our offices.

To ensure your data and your patient’s data are as secure as possible, we’ve implemented additional security for prism accounts.

Dear BCN-Affiliated Medical Care Group Business Administrator:

We’d like to invite you, your primary care physicians, clinicians, pharmacists and support staff to an upcoming webinar discussing Blue Care Network’s precision medicine pharmacogenomics (PGx) program called Blue Cross Personalized MedicineSM.

Loeks Theatre (via Lucent Health) is now a new employer group that has joined the Lakeland Care Network.

Some Cigna member claims submitted electronically by Michigan providers are being incorrectly denied due to a clinical edit. (The remittance advice will usually mention a missing or invalid diagnosis code.) We’re working hard to fix this as quickly as possible.

On June 1, 2023, Akorn Pharmaceuticals initiated a voluntary recall of various products as a result of bankruptcy and discontinuation of quality assurance activities of these marketed products. The discontinuation of the quality assurance program means the company is not able to support or guarantee that the products meet all intended specifications.

On June 1, 2023, Akorn Pharmaceuticals initiated a voluntary recall of various products as a result of bankruptcy and discontinuation of quality assurance activities of these marketed products. The discontinuation of the quality assurance program means the company is not able to support or guarantee that the products meet all intended specifications.

Would you and your team like to learn more about a method of Claim Denial Prevention? We would like to help. Please join us to learn more about the Optum Communication Gateway, which delivers payer-specific rules within the billing workflow and could significantly cut down on your administrative costs of rework.

InterQual, managed by Change Healthcare, is experiencing a national outage. This outage impacts prior authorization processes for providers and payors across the country.

The issue with Medicaid edit 5167 incorrectly front-end rejecting claims, first discovered on May 23, was resolved on May 30. All impacted claims have been reprocessed.

United Healthcare has shared their Network News updates for June 2023

Priority Health is offering an one hour webinar on thursday, June 8, 2023 at noon on the topic of Virtual Office Advisory.

This issue of BCN, Partners in Care, introduces BCN’s Chief Medical Officer Peter T. Graham, M.D., and focuses on how we’re working to improve the experience you and your providers have with us and collaborate with you to improve your patients’ health care experience.

Priority Health is experiencing an issue with their Medicaid claims front-end rejecting for “Claim Type Requires a Referring/Ordering NPI” when they shouldn’t.  Priority Health teams are working to find the root cause and fix the issue as quickly as possible. Until then, they recommend you don't rebill those claims!

On Jan. 1, 2023, CMS released two new care management codes for chronic pain management – G3002 and G3003 – which allow providers helping chronic pain patients to bundle key services and bill monthly rather than a’ la carte.