02/14/2024

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. 

Billing & Coding Tips - Prism Tips
Choosing a claim inquiry dropdown option
Clinical edits vs other related claims When contacting us about a claim, always choose the most appropriate and specific inquiry dropdown option in prism. Choosing incorrectly can increase your response time by 15 days or more as we work to route your inquiry to the appropriate team. Below is a closer look at two dropdown options that are frequently selected incorrectly:

When you have multiple claims with the same issue
We’re in the process of posting 2024 fee schedules, with individual and commercial fee schedules already online. We continually monitor the state and national benchmarks for fee schedule updates, making all required updates in our system within 30 days of a change.

We don’t retroactively adjust any claims paid while we’re loading new rates into our system. To make sure your claims are processed and reimbursed under new rates, you can choose to hold them until you see the new fee schedules posted in prism.

Check for 2024 fee schedules 
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Medicare & Medicaid Quality
Together, we can close your patients’ gaps in care. From preventative screenings to managing chronic conditions, we’re here to support you.

Get our latest Medicare & Medicaid quality newsletter to learn about member campaigns and resources, how to maximize your 2024 PIP incentives and more.

Download the guide 

Incentive Programs
We appreciate your partnership as we work to provide the right care, at the right time, in the right place and at the right cost. We’re continually evolving our incentive programs to help us achieve these goals and to recognize the hard work you do to keep our members healthy. Below you’ll find key incentive program updates and deadlines for the first quarter of 2024.

2024 PCP Incentive Program (PIP)
Our 2024 PIP program is a continuation is the 2023 model, with a few adjustments including:

• Two new pediatric focus measures
• A simplified payout methodology for the focus measures
• A new social determinants of health (SDoH) screening measure
• Updated care management measure, with the addition of CPT codes for touchpoint credit and a simplified link to quality

Additionally, as announced last September, Patient Profile and the PIP_70 report will retire on Feb. 1, 2024 as part of our Digital First data strategy. We’ll continue accepting Patient Profile and PIP_70 reports for gap closures for 2023 dates of service through Jan. 31. We’ve been working closely with ACNs to ensure a smooth transition and effective gap closure for the 2024 performance year.

We encourage you to work with your ACN to ensure your hard work is captured through this Digital First strategy.

See our PIP 2024 manual 
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2024 Disease Burden Management (DBM) Program
We know the hard work you put into population health and chronic condition management in your practices. We want to make capturing important information about your patients easier and more efficient so you can focus your time on what matters most – your patients, our members.

Based on your feedback, we retired our Advanced Health Assessment (AHA) and Persistency programs effective Dec. 31, 2023. We’ll continue accepting claims with 2023 dates of service through Feb. 29, 2024, to ensure complete final payouts for both programs. To continue our partnership focused on improving patient outcomes, we’ve launched the 2024 Disease Burden Management program (DBM). You can find information on eligibility, incentives and program details in our DBM manual.

Note: to be eligible for this program, you must be affiliated with an ACN.

2024 DBM program manual 
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We’re committed to ensuring you have all the tools you need to be successful in our programs. We recently held a webinar with valuable information on how to be successful in the new program.

Watch the webinar

Provider Roster Application (PRA) The monthly PRA attestation schedule continues in 2024. ACNs participating in the following programs must attest to their PCP rosters monthly:

• PIP
• DBM
• Alternative Payment Models (APM)

To get the 2024 attestation calendar and details about how to effectively use PRA (including batch attestations and creating groups / subgroups for your roster), see our updated PRA manual.

Get the 2024 PRA manual 
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Important incentive program dates
Mark your calendars for these upcoming deadlines for the 2024 program year:

• Jan. 31 – Supplemental data submission deadline for Patient Profile, Report 70, MiHIN and HL7. Files submitted after this date won’t be in year-end settlement.
• Feb. 28 – Claims submission and adjudication deadline. All 2023 claims must be billed and adjudicated by the Priority Health system by this date.

Reminder: Cost Estimator No Longer Includes Estimates for Medicare Members
Priority Health’s Cost Estimator tool only works for commercial (group and individual) members, as of Jan. 1, 2024. If you try to access the tool through Member Inquiry on behalf of a Medicare member, you’ll encounter an error. 

Cost Estimator continues to not be available for Medicaid members. 

Please see this January news update for more information, including a provider guide to accessing Cost Estimator through prism and provider FAQs.

2024 PriorityMedicare D-SNP Model of Care (MOC) Provider Training is Now Available
Providers play an integral role in the care teams that support our dual-eligible special needs (D-SNP) 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. This includes specialists, ancillary providers, or anyone part of an ICT (interdisciplinary care team) for a D-SNP member. This is a CMS requirement.

Training needs to be completed and attested to by December 31, 2024. Late submissions will not be accepted.

How to complete training
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, fill out the roster template with 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.

When an attestation is submitted, one of two automated messages will be sent: 

• A confirmation email stating the roster was successfully processed.
• An email stating the roster wasn’t processed and the reason(s) why.

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

Certification of completion
Providers who take online training can download a certificate of completion by clicking the certification icon in the webinar console.

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

Letter from David Rzeszutko, MD, MBA, Vice President, Medical and Clinical Operations
Every year presents a fresh opportunity to reflect and appreciate the work we’ve accomplished together to improve the health of our communities. Thank you for your support in 2023; we look forward to another year of working together.

While 2024 is well underway, our priorities remain the same – to drive better health outcomes for your patients, our members.

Mental health treatment when members need it most
Winter is a challenging season for mental health, and we want to ensure our members have access to the care they need. Most of our commercial and Medicare member health plans include intensive outpatient behavioral health services through our Community Care Management (CCM) program. CCM helps members navigate the transition back to their homes after receiving inpatient or partial hospitalization psychiatric care to support their recovery and reduce readmissions.

Through CCM, we offer our members critical, time-sensitive support until they feel ready to access traditional outpatient care. The program staff, including masters-level therapists, provide short-term support and monitoring to high-risk individuals, particularly those who:

• Were discharged from a high level of care (psychiatric inpatient, partial hospitalization, or crisis residential care) and require intensive support.
• May be at risk of requiring hospitalization, without intervention.
• Need additional support beyond what traditional outpatient therapy can offer.

Learn how CCM goes beyond traditional outpatient care, about member eligibility and coverage options – including how to make a referral and more.

Thank you for your continued commitment to the health and wellbeing of your patients, our members. We look forward to another year of partnership and wish you all the best this year.

Sincerely,
Dr. David C. Rzeszutko