07/18/2023

Priority Health Update

Priority Health Managed Care Committee Member

Flora Werle - Cancer & Hematology Centers of West Michigan

Recall of Multiple Drugs Manufactured by Akorn Pharmaceuticals
On Jun. 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.

A full list of impacted drugs can be found on the FDA Enforcement Report at fda.gov.

We’re notifying members
4,935 Priority Health members are impacted by this recall. We’re sending letters this week to those members, asking that they contact their provider for different treatment options, and to dispose of any current or unused products.

What do providers need to do?
If your patients contact you, work with them on alternative options. As all drugs recalled are generics, other generic options from different manufacturers may be available. Pharmacies are also contacting any patients who have received a recalled product and may be able to replace with another generic from a different manufacturer.

Questions? 
More information on this recall can be found at fda.gov.

We’re Working to Fix Incorrectly Denied Claims for Cigna Members
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.

We’re pausing the edit in question as soon as possible to limit the number of impacted claims while we work to resolve the issue. The edit will be paused starting the week of July 11. 

Once the issue is fixed, we’ll reprocess all incorrectly denied claims. You don’t need to resubmit these claims.

We apologize for any inconvenience this caused. Thank you for your continued partnership.

Reminder: You Must Refer Members to In-Network Providers, Including Labs
To help ensure our members get the highest quality, most affordable health care through our network partners, you’re required to use labs that participate in Priority Health’s network. Participating providers have a contractual obligation to use in-network providers when referring our members for services, regardless of your own contracts for referrals with non-participating labs. 

Out-of-network labs are not covered for members with HMO plans without an approved authorization, even if the lab is performed on the same day as an office visit with a participating provider.

If an out-of-network lab is necessary for a particular service, a prior-authorization is required. (Learn more about reference lab billing here.)

If an HMO member chooses an out-of-network lab despite the provider’s guidance, the member is responsible for the payment. Under Michigan’s surprise billing legislation, for this to occur, the member must sign documentation from the provider that includes:

• A statement that their insurer may not cover all services
• A "good-faith" estimate for services to be provided
• A statement that the member may request care from an in-network provider and can contact their health plan to discuss

What should providers and facilities do?

Refer your patients to in-network providers and facilities. Use our Find a Doctor tool on priorityhealth.com to find labs that are in-network for your patient’s unique plan. If an out-of-network lab is the only option, follow the steps to request an authorization.

If a Priority Health member chooses to use an out-of-network provider or facility without prior approval, inform the member in writing that they will be responsible for any costs, and ensure you have a documented signature from them affirming their choice.

We’re always here to help
If you can’t find an in-network lab using the Find a Doctor tool, contact the Provider Helpline at 800.942.4765.

Reminder to Complete 2023 Priority Medicare D-SNP Model of Care (MOC) Training
Providers play an integral role in the care teams that support our dual-eligible special needs members. That's why the Centers for Medicare and Medicaid Services (CMS) requires us to make sure providers who are contracted with us to see PriorityMedicare patients are trained on our Model of Care. Our Model of Care is a quality improvement tool that ensures the unique needs of our D-SNP members are met and describes the processes and systems we use to coordinate their care.

Who needs to complete Model of Care training?
All providers who are part of the Priority Health Medicare Advantage network need to complete training because PriorityMedicare D-SNP uses the Priority Health Medicare network.

How to access training
Training can be completed using one of two options:

• Option 1 (highly recommended):
  Providers can access Model of Care training as an on-demand webinar. It takes 15 minutes to complete and can be accessed here. Providers who register for the online training will automatically be attested for training, with no form required.
  • 2023 PriorityMedicare D-SNP Model of Care training 
• Option 2:
  We can supply the training deck to your group to be distributed in your preferred format. This option works best if an existing process is in place for other provider training obligations, like compliance training.

All training and attestations must be completed no later than Dec. 31, 2023. 

Additional resources
For more information about PriorityMedicare D-SNP, reference the Provider Manual. 

Post-PHE Coverage Changes for Your Patients & Virtual Care Billing Updates
On May 11, 2023, the COVID-19 public health emergency (PHE) is scheduled to end.

The PHE allowed for member cost share flexibility within their health plan for COVID-19 related claims. The end of PHE will mark several cost share and coverage changes for testing, vaccines and more.

Here’s a summary of the updates that will take place on May 12:

Tests
Diagnostic Tests

• Commercial, Individual/ACA, Medicare: Medically necessary COVID-19 diagnostic tests will return to a lab/ER benefit as appropriate and with applicable copays, coinsurance or deductibles based on a member’s plan type.
• Medicaid: Medically necessary COVID-19 diagnostic tests will be covered with a $0 cost share through September 2024. After that date, there may be a limit to the number of covered tests or nominal cost-sharing.

OTC (Over the Counter) at-home test kits

• Commercial, Individual/ACA, Medicare: OTC test kits will no longer be covered.
• Medicaid: At-home test kits will be covered for free through September 2024. After that date, OTC tests may no longer be covered.

Vaccines
COVID-19 vaccines administered at an in-network provider are covered* as a preventive benefit with $0 member cost share. We’ll no longer cover COVID-19 vaccines administered at an out-of-network provider.

*Exception: Members enrolled in grandfathered and retiree commercial plans should check their plan documents to determine vaccine coverage.

Pharmaceutical treatments
Pharmaceutical COVID-19 treatments will be covered as any other pharmaceutical treatment, with applicable copays, coinsurance or deductibles based on a member’s plan type.

Virtual Care
Coverage
Medicare: Virtual care coverage remains the same until December 2024.

Medicaid: Virtual care coverage remains the same.

Commercial, Individual / ACA: Several codes are listed in our Telemedicine medical policy (#91604) as “Temporary additions for the PHE for the COVID-19 pandemic.” After a thorough review, we’ve determined to continue to cover many of these services when performed virtually.

However, coverage for some of these visits performed virtually will end when the PHE ends, including (but not limited to) temporary additions for:

• Audiometry, evaluation of auditory function for surgically implanted devices and diagnostic analysis of cochlear implant
• Brief emotional/behavioral assessment with standardized instrument
• Emergency department visits for evaluation and management
• Initial hospital care and subsequent intensive care for neonatal patient
• Ophthalmological services
• Psychological or neuropsychological test administration with automated instrument
• Self-measured blood pressure
• Standardized cognitive performance testing

The updated Telemedicine medical policy (#91604) will be released on May 11, 2023. All billing and coding updates will be effective May 12, 2023.

Place of service (POS) codes
In 2021, we reverted to requiring professional providers to bill POS codes 02 or 10 for virtual services, as this was the standard prior to the COVID-19 PHE. CMS and MDHHS recently released updated telehealth guidelines, and we’re making the following update to align all our plans to a new standard virtual care billing criteria.

Effective July 1, 2023, professional providers performing virtual services for any Priority Health member ¬should bill the POS code specific to the location where the member would have been seen in person, along with the appropriate modifier to indicate the virtual care method used:

• 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System
• 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
• GQ: Via asynchronous telecommunications system

Providers can begin billing as described above on May 12, 2023. We’ll also accept POS 02 and 10 through July 1, 2023.

Be sure to reference our Telemedicine medical policy (#91604) which outlines how our Commercial and Individual ACA plans adhere to the list of services defined for synchronous and asynchronous telehealth services.

We’ll follow the telehealth guidelines defined by CMS and MDHHS for Medicare and Medicaid respectively:

• For Medicaid, click here to go to the MDHHS website and then select Billing and Reimbursement then Provider Specific Information – telehealth
• For Medicare, reference CMS’ Medicare Physician Fee Schedule Final Rule Summary: CY 2023 (MM12982) and the codes found in CMS’ List of Telehealth Services

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