Complete Story
10/24/2022
Priority Health Update
Priority Health Managed Care Committee Member
Flora Varga, Cancer & Hematology Centers of West Michigan
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We're working to fix a chemotherapy clinical edit error
A clinical edit for chemotherapy administration, active since June 28, 2022, has been incorrectly denying the following services across all product lines when it shouldn’t:
- CPT codes 96401-96450, 96542-96549, 0708T, 0709T when billed with either
- Z51.11 (encounter for antineoplastic chemotherapy) or Z51.12 (encounter for antineoplastic immunotherapy) as the primary diagnosis
We’re working diligently to fix this issue.
There’s no need to resubmit impacted claims. We’ll automatically reprocess them once the issue is resolved.
We're reviewing the implementation of four clinical edits
Ensuring you're reimbursed fairly and accurately for the services you provide our members is of the utmost importance to us. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently. We're constantly monitoring our edits to make sure they're working as they should.
Through this review, we've decided to pause the four edits listed below to make sure they're following our medical policies as they should.
There's no need to resubmit any claims denied due to these edits. We'll automatically reprocess them for payment as appropriate.
Clinical edits to be paused on Oct. 25, 2022
The following clinical edits will be paused while our Payment Integrity team assesses any necessary modifications:
- Deny any code billed by a DME provider when the code isn’t a DME code
- Deny professional radiology services when billed by a provider other than an anesthesiologist, cardiologist, multi-specialist, neurologist, physical medicine specialist, radiologist, or radiation oncologist in the inpatient or outpatient hospital setting
Clinical edits will be modified on Oct. 25, 2022
We've identified the modifications needed for the following edits to align with our medical policies.
- Deny chemotherapy administration when the primary or principal diagnosis isn’t an encounter for antineoplastic chemotherapy or antineoplastic immunotherapy.
This edit will be modified to look at the claim line rather than the claim header for all lines of business. - Deny A4305, A4306 (Disposable drug delivery system), or A9274 (External ambulatory insulin delivery system, disposable) when billed as a noncovered item.
This edit will be modified so that it's turned off for Commercial and Medicaid. It will remain on for Medicare.
HRA incentive open to more providers in 2023
In 2023, we’re updating our Healthy Michigan Plan (HMP) measure to open the opportunity to earn the Health Risk Assessment (HRA) incentive payment to more providers, more frequently.
What’s changing?
The HRA incentive will not be part of the PCP Incentive Program (PIP) in 2023. This shift allows us to open the measure and incentive opportunity to independent PCPs. Additionally, Advanced Practice Professionals (APPs) will be eligible to participate in the incentive for the first time.
How can you participate?
To participate in the HRA measure and be eligible for quarterly payments, a credentialed PCP / APP must:
- Complete the HRA form for eligible HMP members during the 2023 program year. One form per member per year is eligible for the incentive payment.
- Submit the completed HRA form using CHAMPs or fax. The form must be received no later than 30 days after the end of the quarterly payout period it was completed in.
Find more details in our 2023 HRA technical specifications document.
How much can you earn?
The incentive payment for each eligible form submitted is $25.
What’s the 2023 schedule?
We’ll make quarterly payments in 2023 following this schedule:
|
HRA completion dates |
Submission deadline |
Payment payout |
|
January 1 - March 31 |
Apr. 30, 2023 |
June 1, 2023 |
|
April 1 - June 30 |
July 30, 2023 |
Sep. 1, 2023 |
|
July 1 - September 30 |
Oct. 30, 2023 |
Dec. 1, 2023 |
|
October 1 - December 31 |
Jan. 30, 2024 |
Mar. 1, 2024 |
PriorityWell Choice Benefits launching Dec. 1, 2022 for commercial large groups; HealthbyChoice retiring by 2024
What’s new
PriorityWell Choice Benefits (PWCB) will be available for fully and self-funded large groups beginning Dec. 1, 2022, with small group availability beginning in 2024. The new product was developed to encourage year-round engagement for members, with an elevated member experience from HealthbyChoice. Groups who are currently enrolled in HbC will start transitioning to PWCB based on their renewal date. HbC will sunset from the product portfolio over the next two years.
What’s changing for providers
There’ll be a new biometric screening form for this product that providers will be asked to fill out for their patients who are enrolled in PWCB. Providers can expect to see this form beginning Dec. 1, 2022 and beyond. Unlike the current HealthbyChice form, providers won’t be required to submit this new PWCB form to Priority Health. The member will be responsible for submitting the form through their Virgin Pulse account.
This new wellness plan doesn’t reimburse providers for form submissions since members are responsible to submit the form. However, while members are still transitioning from HbC to PWCB, providers will continue to be reimbursed $30 for any HbC forms that are submitted to Priority Health through the HealthbyChoice portal until the product has completely retired in 2024.
What else providers need to know
The HealthbyChoice form can’t be used as a substitute for the new PriorityWell Choice Benefits form
- An example of the new form can be provided to provider offices upon request. Please don’t duplicate/circulate to members, as the information on the form is distinct to their employer and as an individual
Visit the Priority Health Provider News Page for Additional Updates: CLICK HERE
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