05/11/2023

Priority Health Update

Priority Health Managed Care Committee Member

Flora Werle - Cancer & Hematology Centers of West Michigan

Physician and Practice News Digest: Quarter 2 

• Help your patients prepare for the end of the Public Health Emergency (PHE)

• Billing and coding tips

• Medicare & Medicaid quality

• Value-based incentive programs

New Pop-Ups in GuidingCare Help You Submit Accurate, Necessary Authorizatoin Requests
You’ll start to see new pop-up messages in our authorization portal, GuidingCare which will help you submit accurate authorization requests—and avoid submitting unnecessary ones.

These new messages pop up, when appropriate, before you submit your authorization request. They use the information entered to:

• Identify procedures that don’t require an authorization
• Indicate that the member may have another primary insurance policy
• Alert you when a requested service should be run through eviCore rather than GuidingCare

Learn more
To see screenshots of these new pop-up messages, along with descriptions of when they’ll appear and how to interact with them, download our GuidingCare Quick Start Guide.

READ MORE

Two Midnight Rule: Our UM Practices Will Remain Unchanged
At Priority Health, our members’ health is our top priority. This is why we’ve built a robust utilization management (UM) program, working with our contracted providers to ensure our members get the right care at the right time.

Through this UM program, we review every inpatient admission upon admission, not just short stays or those that meet or exceed two midnights. CMS affords us this opportunity as a Medicare Advantage (MA) plan, and its recent 2024 policy update document doesn’t change that.

Our UM program will remain unchanged, and our providers will continue to work with us as they have.

READ MORE 

Formulary Changes Coming July 1, 2023
In January and July of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial and individual formularies to ensure our members have access to safe, effective and affordable drugs.

Commercial formulary changes effective Jul. 1, 2023
This year we’ve made more than 100 enhancements to the commercial formulary, including 51 new drugs added to the formulary and changes to 53 current drugs.

Effective Jul. 1, 2023, nine drug changes will go into effect that will either increase the drug tier, increase cost share or add prior authorization requirements. These changes will impact 22 members.

SaveOnSP
Additionally, 32 drug changes will go into effect that will either remove or add specialty drugs at the $0 out of pocket cost through the SaveOnSP (SOSP) program. These changes will impact 238 members. See approved language section for the tables detailing drug changes and specific member impact numbers.

Formulary changes impacting < 25 members
*Some members may experience a cost share increase with reduced drug tier due to unique plan designs.

Continuous Glucose Monitor (CGM) Changes Impacting 100 + Members

How we're communicating to members
Impacted members will receive a letter advising them of their drug coverage or continuous glucose monitor (CGM) changes and what steps they can take prior to July 1, 2023. If an alternative medication is available, those options will be listed.

SaveOnSP will send a letter to affected members enrolled in the program, advising them of added or removed specialty drugs prior to Jul. 1, 2023.

What do you need to do?
You can proactively reach out to your patients impacted by these changes by referring to the member impact list your provider performance specialist shared with you and offering alternative treatment options. Your patients may also reach out to you to discuss alternative medications or how to submit a proper diagnosis to us.

Learn more
These changes will be reviewed at our June 8 Virtual Office Advisory. Join us to ask questions and learn more.

GuidingCare was Recently Updated & CPT Code 99222 Can No Longer be Used For Authorization Requests
CPT code 99222 is no longer accepted when entering authorization requests in GuidingCare. If used, you’ll see the message below pop up on your screen:

"An authorization cannot be processed for this service. Please check the Priority Health website for information on services that require prior authorization."

Our GuidingCare authorization guides list the appropriate procedure / revenue codes to use when entering your requests. To access the guides:

1. Log into your prism account 
2. Open the Authorizations menu
3. Click Request an auth
4. Click Auth request help page

Michigan Medicaid Redetermination is Restarting June 1, 2023
Beginning June 1, 2023, the state of Michigan is restarting full eligibility reviews for D-SNP, Healthy Michigan and Medicaid members.

What is Medicaid redetermination?
Medicaid redetermination is the process by which Medicaid members must reapply for their Medicaid benefits and prove they qualify for Medicaid. In Spring 2020, the federal government issued a COVID Public Health Emergency (PHE) which resulted in the Medicaid redetermination process being put on hold during the PHE. Prior to 2020, Medicaid members were sent notifications, advising them to reapply for benefits and verify their income on a 12-month rolling basis. This process will resume in June.

To learn more about Medicaid redetermination, visit the MDHHS website. 

How we’re communicating to members
The Michigan Department of Health & Human services (MDHHS) will send renewal packets by mail, text message or via the member’s MIBridges account one month prior to their renewal date. For example, members with a June renewal date will receive communications in May. We’re also sending MDHHS-approved communications about Medicaid renewals to all Medicaid members prior to their renewal date and after their renewal date passes.

What should providers know?

• To ensure you get paid, check their Medicaid patient’s coverage prior to providing services. Members may lose coverage if they didn’t renew their information or if they couldn’t be contacted during their Medicaid re-enrollment period.
• If a member no longer has Medicaid coverage and believes they still qualify, they’ll need to reapply through their MI Bridges account, by calling the Medicaid Beneficiary Hotline at 1-800-642-3195 or by visiting their local MDHHS office.
• If a member is no longer eligible for Medicaid after a full renewal, they’ll receive information on when enrollment ends, how to appeal and to enroll in other health coverage.

Learn more
We’ve also included this information in the April 13 Virtual Office Advisory (VOA) and the Q2 quarterly physician & practice news digest and will continue sharing resources including approved messaging by the state, webinars and more.

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