03/18/2024

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. 

Change Healthcare Outage Update: Availity Clearinghouse Now Set Up, Cap and Admin Payments Releasing this Week

Professional Providers: POS 02 Virtual Care Services Reimbursed at Facility-Based Rate Starting May 1
Effective May 1, 2024, we’re aligning with CMS on our reimbursement rate for professional virtual care services based on the reported place of service (POS) code.

Why are we making this change?
This update aligns with CMS’s recent reimbursement changes that went into effect on Jan. 1, 2024.

Our Updated 2024 PIP Manual is Now Available
We recently updated our 2024 PCP Incentive Program (PIP) manual (login required). Below is a summary of the changes:

Page 6: 2024 program measure grid
The commercial 90th percentile target was incorrect in the manual. The correct target is 46%

Page 19: Social Determinants of Health Screening
Added an additional screening code (G0136) that will count as numerator compliance.

Page 42: Appendix 5: Report inventory
Added Medicaid members’ foster care eligibility (start) dates to the following PIP reports:

• HEDIS Gaps in Care (PIP_11C)
• Membership Eligibility (PIP_075)

Removed CCDA and MiHIN PPQC data submission verification as available confirmation reports. These reports are not available currently.

Page 43: Appendix 6: Appropriate statin use in diabetic patients
Updated measure and medication information and tips for success.

Page 46: Appendix 7: Medication adherence in patients with diabetes, hypertension and high cholesterol
Updated measure and medication information and tips for success.

Medicaid Providers: Make Sure Your Primary Specialty is Entered in CHAMPS
To align with MDHHS, we’re updating our Medicaid edit 5169 to more accurately validate claims from providers enrolled in CHAMPS as “individual/sole proprietor.” The edit will reference the CHAMPS provider enrollment form’s Primary Specialty field to determine whether a provider is an approved provider type.

If the Primary Specialty field isn’t filled in when the edit logic is updated, providers will see an increase in front-end rejected claims.

We’re aiming to have the edit’s logic updated in the next 90 days and will send a follow-up communication with the exact date.

Fewer requests for providers to reimburse inaccurate payments Medicaid edit 5169 rejects claims for "non-approved provider types” found in the Attending, Ordering or Referring fields for claims submitted by those registered in CHAMPS as individual/sole proprietors.

The state’s 5169 edit validates provider type using CHAMPS Primary Specialty field. This data was recently made available to health plans. Aligning our data sources for this edit with the state’s will lead to:

• More accurate validation of Medicaid-approved provider types on the claims
• Fewer claim rejections from the state
• Fewer requests for providers to reimburse inaccurate payments

What do you need to do?
If you're enrolled in CHAMPS as “Individual / Sole Proprietor”, verify the following before submitting claims for Medicaid members. Make sure:

1. You're active in CHAMPS on the date of service.
2. Your Primary Specialty in CHAMPS is complete and an approved provider type.

If you see an increase in 5169 front-end rejected claims after the edit’s logic is updated, you should verify the above and then resubmit your claims.

Note: Medical necessity review doesn’t verify provider type.
Providers with approved authorization requests for Medicaid members may still see claim denials if their CHAMPS Primary Specialty isn’t filled out or isn’t an approved provider type.

New Medical Exam Requirements for Medicaid Members in Foster Care
The Michigan Department of Health and Human Services (MDHHS) released new medical exam requirements for Medicaid health plans and providers serving children in foster care.

These new requirements go into effect in March. With roughly 10,000 children in foster care at any given time, PCPs could see an increase in scheduling demand.

Requirement 1
Medicaid beneficiaries in foster care must complete a medical exam within 30 days of entering foster care.

This exam is required and will be covered at no cost to the member, regardless of the date of their last medical exam. Additionally, children in foster care require the following services:

• Ages 0-20 years: All appropriate medical exams (EPSDT or Well-Child Exam) for their age
• Ages 3 years and older: Dental exam within 90 days of entering foster care unless the child had a dental exam within six months prior to the date

Our care management team is actively involved in reaching out to foster parents or caregivers to schedule needed exams within the MDHHS timelines.

Requirement 2
Health plans must allow Medicaid members in foster care to maintain their current PCP.

This applies to PCPs within a reasonable distance of the member’s foster care living arrangement, for both in and out-of-network providers.

2024 PIP reports to show Medicaid members’ foster care start dates

To support compliance with these new guidelines, we added Medicaid members’ foster care eligibility (start) dates to the following PCP Incentive Program (PIP) reports:

• HEDIS Gaps in Care (PIP_11C)
• Membership Eligibility (PIP_075)

You’ll see this information at the end of each report in a column titled “Medicaid Foster Eligibility Date” when the 2024 PIP reports are released in April.

March 4 Change Healthcare Outage Update: Clarification on Clearinghouses
March 4, 2024

Even if you do not work directly with Change Healthcare, you may still be impacted by the outage. In many cases, Change Healthcare operates as a secondary clearinghouse to route claim and remittance advice files to the appropriate recipients.

If you have not received ERAs, contact your clearinghouse for a status on changes to their operations for sending and receiving these transactions.

See our latest news items about the Change Healthcare outage: 

• Feb. 22: prism and pharmacy claims impacted by Change Healthcare major incident 
• Feb. 26: Ongoing impacts from the Change Healthcare outage 
• Feb. 28: Change Healthcare outage update: Other clearinghouses available