Complete Story
09/19/2023
Priority Health Update
Priority Health Managed Care Committee Member
Flora Werle - Cancer & Hematology Centers of West Michigan
Reminder: Use a Street Address for the Billing Provider Address on Medicaid Claim Forms
Updated 8/24/23 to clarify between forms 1500 and 837P
Per HIPAA standard and NUCC guidance, the Billing Provider Address field on Medicaid claim forms —both paper and electronic (EDI) – must be a street address. We occasionally see Medicaid claims with a P.O. Box address in this field, which isn’t allowed.
How we’re addressing the issue
- Currently, payments for claims found to have this error will be recovered. Providers can rebill with the appropriate address information.
- In the future, we hope to implement an edit which will front-end reject claims with this error back to the provider.
What you can do
Here’s how to avoid claim adjustments due to this error by claim form type:
|
Claim form type |
How to bill |
How we'll pay |
|
1500 (paper) |
Use a physical address* in the Billing Address field (item 33). |
We’ll issue payment to the remit address that’s in our system. |
|
837P (EDI) |
Use a physical address* in the Billing Address field. A P.O Box is allowed in the Pay To field. |
*Don’t have a physical address? Use your servicing location.
Updating your remit address
If your remit address in our system is incorrect, you can update it in prism. Learn how.
Still Getting Your Service Receipts by Mail or Fax? Update to Electronic Delivery Today.
We send service receipts out daily to provider offices. These receipts summarize the number of claims submitted to Priority Health and list any claims rejected up front for invalid or missing data elements.
If your office is still receiving these receipts by mail or fax, we highly recommend updating to electronic delivery. Getting them via email can:
- Ease your administrative burden
- Alert you to any front-end rejected claims sooner and ultimately
- Speed up payment on these front-end rejected claims
We can email service receipts to multiple addresses if needed. To get started, fill out the quick form linked below.
Digital First: Submitting Supplemental Data in 2024
As health care continues to transition into the digital space, we’re adapting our data strategy to follow suit.
Patient Profile and the PIP_70 report will be retired with the close of the 2023 PIP performance year. Beginning with the 2024 performance year, we’ll accept only the following supplemental data sources for quality gap closure:
- Claims
- CPT II codes
- Direct data feeds (HL7 or APS)
- MiHIN
- MICR (immunizations)
- Epic Payer Platform (EPP)
- Disease registry
- Continuity of Care Documents (CCDs)
Edits Checker and Prism's Clinical Edits Details are Back Online
Our Edits Checker tool, which allows you to see how edits may apply to a claim scenario before billing, was briefly offline. The tool is now back up and running for both professional and facility claims.
Additionally, for claims already billed, you should now be able to see in prism any clinical edits that applied to your claims. For details:
- Log into prism.
- Within the Claims menu, click Medical Claims and search for the claim in question.
- Click Claim Details.
- Under Clinical Edits, click See Edits.
Join Us for Our Next Virtual Office Advisory (VOA) on October 12
Join us for our next Virtual Office Advisory webinar at noon on October 12 and learn about:
- prism security updates, including information on prism security administrators (pSAs) and how to assign one
- Behavioral health updates, including information on community care management (CCM) and our self-help mental wellness tool
- Medicare quality updates, including Q4 member campaigns, 90-day prescription refills and 2024 CMS star ratings updates
- 2024 Priority Health product updates, including updates on group commercial, individual, Medicare Advantage and D-SNP products
- A 2024 PIP program overview, including updates, information about our digital first strategy and a sneak preview of our preliminary 2024 PIP Manual
How to register
You and your providers can join us by registering online.
Can’t join us?
All VOAs are recorded and posted to our website within a week of the webinar, so you can watch at your convenience.
Tezspire Coverage to Shift from Medical to Pharmacy Benefit Effective Jan. 1, 2024
Effective Jan. 1, 2024, Tezspire® coverage will shift from a medical benefit to a pharmacy benefit for commercial and individual lines of business.
What’s changing?
Beginning Sep. 1, 2023, coverage for the Tezspire autoinjector pen will be added to the pharmacy benefit as a Tier 4 medication with prior authorization criteria.
Beginning Jan. 1, 2024, Tezspire will no longer be covered under the medical benefit and the prefilled syringe will not be added to the pharmacy benefit.
Click here to visit the Priority Health Provider News Page for additional updates.
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