11/30/2022

Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga, Cancer & Hematology Centers of West Michigan

Get Your Questions Answered
Do you have questions you need answered by Priority Health? For a resource to help you navigate the online provider portal, Prism, CLICK HERE. 

Commercial HMO, EPO, POS, and PPO Plan Fee Schedules
Before contacting the contract department regarding fee schedule questions, review all fee schedules listed below to identify the one most applicable to your practice type.

Click here to view our standard fee schedules. All fee schedule updates are uploaded into our system in 30 days or less. We do not make retro-adjustments to any claims paid while we're loading the new rates into our system. To ensure your claims are processed and reimbursed under the new rates, you can choose to hold your claims until you see the new fee schedules are posted to the Provider Center.

Medicare Fee Schedules
Before contacting the contract department regarding fee schedule questions, review all fee schedules listed below to identify the one most applicable to your practice type.

We continuously monitor CMS, WPS, and MDHHS for fee schedule updates. All fee schedule updates are uploaded into our system in 30 days or less. We do not make retro-adjustments to any claims paid while we are loading the new rates into our system. To ensure your claims are processed and reimbursed under the new rates, you can choose to hold your claims until you see the new fee schedules are posted to the Provider Center.

Click here to view our standard fee schedules. Verify with your contract administrator to see whether or not they apply to you.

Medicaid and Healthy Michigan Plan fee schedules
Before contacting the contract department regarding fee schedule questions, review all fee schedules listed below to identify the one most applicable to your practice type.

We continuously monitor CMS, WPS, and MDHHS for fee schedule updates for claims priced in Facets and have partnered with the vendor Optum to manage claims in Rate Manager. All fee schedule updates are uploaded into our system in 30 days or less. We do not make retro-adjustments to any claims paid while we are loading the new rates into our system. To ensure your claims are processed and reimbursed under the new rates, you can choose to hold your claims until you see the new fee schedules are posted to the Provider Center.

Click here to view our standard fee schedules.

Medicaid capitation methodology
As part of the Total Health Care (THC) Integration, Priority Health has developed a Medicaid capitation methodology for select contracted providers. This methodology is available to primary care providers billing on professional claims in an office setting and currently participate in Medicaid capitation. For example, federal quality health center (FQHC), rural health clinic (RHC) and tribal health clinic (THC) providers don't qualify for capitation due to MDHHS guidelines that require they bill under a facility claim. We’ll work to expand this program to the larger provider network in future years.

What is Medicaid capitation?
Capitation is a per member per month (PMPM) payment based on comprehensive care of your Medicaid membership. It serves as an opportunity for you to engage in a value-based Priority Health Medicaid contract. The capitation methodology applies to specific CPT codes, which are primarily primary care CPT codes. In addition, you must meet utilization, quality and diagnosis capture thresholds.

Capitation primary care codes
Click here to view the codes. 

Capitation utilization and quality metrics
No targets are applied for 2021 capitation. Beginning 2022, 70% of a provider’s member panel must have a primary care visit within the calendar year.

Risk-adjusted target
No targets are applied for 2021 capitation. Beginning 2022, providers must participate in Health Risk Assessment programs. We’ll share more information about Health Risk Assessment programs in the future.

Click here to visit the Priority Health Provider News Page for additional updates.