04/20/2022

Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga, Cancer & Hematology Centers of West Michigan

Change to referring/ordering/attending editing for Medicaid claims
In accordance with the Michigan Department of Health and Human Services (MDHHS), we’ll reject claims when the referring, ordering, or attending providers don’t align with bulletin MSA 21-45 for dates of service 1/1/2022 and after.

How to make sure these claims are paid
Make sure the National Provider Identifier (NPI) reported on the claim is of a provider type consistent with current licensing, scope of practice, and Medicaid policy criteria.

Reference these tip sheets when filing claims: READ MORE

Appeal vs. claims inquiry: Steps for faster claims resolution
As of 11/01/2021, providers have one appeal right for each Priority Health claim. Any future claim corrections performed in the remaining 12 months won't result in additional appeal rights.

With only one appeal right per claim, we ask you to follow the steps below for a faster claim resolution prior to submitting an appeal. It’s important to us that you’re satisfied with the way a claim is handled. If you have a problem, we want you to know what you can do about it.

Step 1: Check the status of your claim - READ MORE

Reminder: CMS' Two-Midnight Rule doesn't apply to Medicare Advantage members
The Centers for Medicare and Medicaid Services’ (CMS) Two-Midnight Rule doesn’t apply to Priority Health members because our members have a Medicare Advantage (MA) plan.

Why doesn't this rule apply to our members?
Our members are part of an MA plan and, therefore, not subject to Medicare Part A rules. Instead, CMS defers to our provider contracts and doesn’t require us to include the Two-Midnight Rule. This allows us, in collaboration with contracted providers, to set our own criteria, as long as our members receive the same benefits as outlined under Medicare Part A.

What is the Two-Midnight Rule?
On Oct. 1, 2013, CMS began using the Two-Midnight Rule. This rule established Medicare payment policy regarding whether an inpatient admission is reasonable and necessary for purposes of payment under Medicare Part A.

In general, the original Two-Midnight rule stated that:
Inpatient admissions would generally be payable under Part A if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation.

Medicare Part A payment was generally not appropriate for hospital stays expected to last less than two midnights.