01/15/2024

Priority Health Update

Priority Health Managed Care Committee Member

Flora Werle - Cancer & Hematology Centers of West Michigan

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

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. To be reimbursed for their services, CHWs must be enrolled in CHAMPS as well as contracted and enrolled in our provider network. We’re now accepting enrollment applications through Prism.

View the final policy MMP 23-74 for more information, including covered services and billing guidelines. 

Enrollment guidelines for CHWs are now available in our Provider Manual. 2024 rates for CHWs will be posted to our Medicaid fee schedules (login required) for “Practitioner/medical clinic” when available from MDHHS.

We're working to resolve Medicaid claims being rejected incorrectly
We’re experiencing an issue with Medicaid claims front-end rejecting for “Referring / Ordering / Attending is not Enrollment Type 1/Individual” when they shouldn’t. This issue started on December 18 and appears to be impacting providers registered in CHAMPS as “Individual / Sole Proprietor”.

Our teams are working diligently to resolve this issue. Until then, please don’t rebill.

Our goal is to reprocess any impacted claims after we’ve fixed the root cause of the issue. If we’re unable to reprocess claims, we’ll publish an update with next steps.

We value your partnership and the care you provide our members, and we sincerely apologize for any inconvenience this has caused. Thank you for your patience and understanding.

Replacing APCD Extracts with Improved, Data-Rich File in the Coming Months
As we continually strive to provide our Accountable Care Networks (ACNs) with accurate, easy-to-use data, we’ll be phasing out our All-Payer Claims Data (APCD) extracts in 2024 – transitioning to a more robust, data-rich file that includes the member and claims data you need.

This transition will take place over the course of several months, during which participating ACNs will have the opportunity to test and update their systems to ingest the new file while still receiving the APCD extracts.

Test our new data dictionary
We’ve made available a data dictionary/file layout to compare what you receive today through APCD with what we’re preparing for the updated files. This Excel spreadsheet lists the fields appearing in each extract with a data description, type, size and format.

Click here to download the data dictionary.

SFTP setup
While APCD files are shared via Filemart, the updated files will be delivered to ACNs by Secure File Transfer Protocol (SFTP). As more of our reports and data move to SFTP , we encourage you to get set up with us if you haven’t already.

Questions, feedback & next steps
In the coming weeks, we’ll connect with ACNs on rollout timing and needs, including a test file tailored to your ACN as well as additional training and materials to support you through this transition.

If you have questions or feedback, or need support getting set up with SFTP, contact your Provider Strategy & Solutions Consultant.

Thank you in advance for your support and partnership.

Register Now for Our 2024 Virtual Office Advisory (VOA) Webinars
Our virtual office advisory (VOA) webinars continue to be a key way of connecting with you and your staff about important updates and reminders.

We’re excited to have connected with more of you than ever before this past year. In 2023, we saw a 39% increase in average attendance from 2022. 

That’s a clear sign to us that the information we’re providing through our VOAs is important to you. So let’s keep it going in 2024.

What are the VOA dates for 2024?

• Feb. 8, 2024: general audience
• Apr. 11, 2024: billers and coders
• June 13, 2024: general audience

Click the links above to register for each respective webinar. No need to wait: registration is already open.

Specific topics will be announced a month prior to each VOA.

Where can I find registration links and recordings of past VOAs all in one convenient place?
All this can be found on the VOA page in our provider manual.

Stay tuned for more news, as we continue working to bring you content that’s relevant to you when it’s most convenient to you.

How to Discharge Patients - the New Process
As we shared in early November, our online patient discharge tool is getting an update. On January 8, the tool was moved to the Member Inquiry section of Prism, from Patient Profile.

Any patient discharges submitted through Patient Profile on or after January 8 won’t be processed.

This change comes as Patient Profile is set to be removed from Prism on February 1 as part of our Digital First data strategy.

Get more information and step-by-step instructions for the new patient discharge process in our Provider Manual. We’ll also cover the process at our February 8 Virtual Office Advisory (VOA) webinar.

Reminder: PSODs Are Required for Procedures, Services That May Not be Covered by Medicare
Pre-service organization determinations (PSODs) are requests used to determine whether an item or service will be covered for a Medicare member.

The PSOD process is like the Traditional Medicare Advanced Beneficiary Notice (ABN) process, protecting all parties involved – the member, provider and Priority Health.

Ensure services not covered, but chosen by the member, don’t become provider liability
When the requested service is covered, we’ll provide the required confirmation. When it’s not covered, we’ll send the Notice of Denial of Medicare Coverage (CMS-10003) to the provider and member. This notice lets the member know they’ll be liable for the cost if they pursue the service.

Bill with modifier GA if the Medicare member decides to move forward with the service knowing coverage has been denied. This will make sure the balance goes to member liability rather than provider liability.

The member, their representative or their provider have the right to request a PSOD.

Learn how to request a PSOD 

Aligning "Assistant at Surgery" Reimbursement Rates with Industry Standard in March
Providing our members, your patients, the right care at the right cost is one of our top priorities as a nonprofit health plan. As we strive to meet this goal, we occasionally identify opportunities to better align our payment strategies with industry standards.

In March, we’ll align our “assistant at surgery” percent reimbursement rate with the Centers of Medicare and Medicaid Services (CMS) standard as follows:

Commercial & Medicare:

Medicaid:
There will be no change for Medicaid as our percent reimbursement is already aligned with industry standard.