Community Health Worker services covered by Medicaid effective Jan. 1, 2024
Effective Jan. 1, 2024, we’ll begin accepting claims for Community Health Worker (CHW) services for Medicaid beneficiaries.

Class I recall of polyvinyl alcohol 1.4% lubricating eye drops
On Nov. 1, 2023, Rugby Laboratories initiated a class I recall for one NDC of polyvinyl alcohol 1.4% lubricating eye drops due to possibility of bacteria due to unsanitary manufacturing conditions. 

A full list of impacted drugs can be found at fda.gov.  

We’re notifying members
19 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 to identify alternative options. Covered alternatives can be found by searching the Approved Drug List (ADL) at priorityhealth.com/formulary.

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

Priority Health November 2023 Medical Policy Updates
Our Medical Advisory Committee (MAC), comprised of network physicians contracted with Priority Health, met in November and approved a series of medical policy updates. The review the document, click here. 

• Obstructive Sleep Apnea #91333
• Autologous Chondrocyte Implant / Meniscal Allograft / Osteochondral Replacement #91443
• Biofeedback #91002
• Bone Density Studies #91494
• Cellular and Gene Therapy #91638
• Colorectal Cancer Screening #91547
• Computerized Tomographic Angiography Coronary Arteries (CCTA) #91614
• Fecal Microbiota trans Fecal Bacteriotherapy #91603
• Gender Affirming Surgery #91612
• Osteoarthritis of the Knee #91571
• Peripheral Nerve Stimulation #91634
• Surgical Treatment of Obesity #91595

Expanded price transparency with our Cost Estimator tool
The way people shop for health care continues to change. Consumers are looking for cost transparency and want to know what they are paying for, the same as if they were shopping for a new car or appliance.   To meet this consumer demand and to meet new government regulations, we’ll begin providing price and cost-sharing information for all covered procedures and services on January 1, 2024, to group and individual commercial members and providers through our Cost Estimator tool in partnership with Healthcare Bluebook. Cost Estimator will still be known by the same name.

Why are we making this change?
On October 29, 2020, the Departments of Health and Human Services (HHS), Treasury and Labor issued the “transparency in coverage” final rule. The rule imposes new transparency requirements on most group health plans and health insurers in the individual and group markets. The purpose of the requirements is to enable consumers to make informed health care purchasing decisions.The final rule requires health plans to disclose prices and cost-sharing information for all covered services, including all encounters, procedures, medical tests, supplies, durable medical equipment and fees (including facility fees). Pricing for medications or other pharmacy benefits will not be included in this change.

What exactly is changing?
We’ve been a leader in the cost transparency space since 2014, when we originally launched the Cost Estimator tool. So this won’t be as much a fundamental shift as just an expansion of what we’ve already been doing.It should be noted that the methodology for calculating a cost estimate is changing. Now, an estimate will be produced using allowed amounts from aggregated claims data. This may result in prices being estimated differently than they previously were.

What is the impact to the Priority Health network?
The new version of the Cost Estimator tool helps members avoid billing surprises by seeing costs ahead of time. Fewer billing surprises means fewer unhappy patients. As with all procedures and services having cost estimates, you may also receive questions from patients about costs or experience the effects of patients shopping for lower costs. We believe that competition is a net positive and a key driver of care affordability.  

Can providers still access Cost Estimator?
Yes, you’ll continue to be able to access Cost Estimator via prism, where you’ll be able to see what your patients see and what their out-of-pocket costs are for services. More details will be coming in early 2024 about how to use the updated provider version of the Cost Estimator tool.

Final 2024 PIP Manual is now available online
The final 2024 PCP Incentive Program (PIP) manual (login required, see PCP Incentive Program) is now available. The following updates were made since the preliminary manual was released on Oct. 3:

2024 Program updates (pg. 5)
The Diabetes Care: HbA1c ≤ 9.0% (HBD) measure name has been updated to Glycemic Status Assessment for patients with Diabetes: HbA1c ≤ 9.0% (GSD), per HEDIS. See the 2024 HEDIS Provider Reference Guide (login required, see Quality Improvement) for more information.

Program measure grid (pg. 6)
The product payout and product targets have been finalized and are included in this final manual. The grid provides an overview of the incentive program, including the measure, product payout and product target.

Get our 2024 HEDIS® Provider Reference Guide
Our 2024 Healthcare Effectiveness and Data Information Set (HEDIS®) guide is now available. This guide serves to support you in your efforts to deliver quality health care to the communities we serve as well as your performance in our provider incentive programs.

To access the guide:

1. Log into your prism account.
2. Navigate to Provider Incentive Programs.
3. Click Quality Improvement.

It’s important to note that the HEDIS guide is a supplemental material and doesn’t replace our PCP Incentive Program (PIP) manual. You’ll continue to use our PIP manual as a reference for your participation in the program.

Haven't attested with Better Doctor? You'll get a call from Command Direct.
We’re working with Command Direct to reach out to providers who haven’t submitted their quarterly attestation through Better Doctor.

Accurate Find A Doctor listings are our goal
By attesting quarterly with Better Doctor, or through Command Direct’s follow-up process, you ensure your listing in our Find A Doctor directory are up-to-date and accurate for members seeking in-network care. These attestations are separate from other attestations you complete, such as CAQH.

You may be removed from our directory if, for example, your practice name doesn’t match the name used when answering the phone, or if other data, like location or hours of operation, are inaccurate.

Reminder to complete D-SNP MOC training by Dec. 31, 2023
Who needs to complete training?
All providers who are part of the Priority Health Medicare Advantage network need to complete training. This includes specialists, ancillary providers, or anyone part of an ICT (interdisciplinary care team) for a D-SNP member. This is a CMS requirement.

How do providers complete the training?
Providers can complete our training using one of two options: 

Option #1: Bulk attestations
You can group our D-SNP MOC training with existing, required training (like compliance training) so you can submit attestation for providers at the same time. If this option is selected, you’ll need to:

1. Distribute training to your providers using this link.
2. To attest to training, you must fill out the roster templatewith providers who’ve received training. If you choose to submit a provider roster, only the Priority Health MOC roster Excel sheet provided will be accepted.
3. Send attestation rosters to DSNPtraining@priorityhealth.com.

Option #2: Virtual training (only takes 15 minutes)
Training is available as an on-demand webinar and only takes 15 minutes for providers to complete. Provider registration for the on-demand webinar counts as attestation, which means no additional documentation is required.

Access online training here.

Be sure to submit the correct provider NPI
Ensure the correct provider NPI number is included when submitting the provider roster or registering for the online training. If the NPI is incorrect, the provider’s status will be marked "incomplete" in our system. To correct an "incomplete" status due to an incorrect NPI, resubmit the provider roster or re-register for the online training with the correct provider NPI.