Complete Story
08/19/2024
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.
Procedure Codes Impacted by the New TurningPoint and EviCore Authorization Programs
We’re working with TurningPoint Healthcare Solutions LLC (TurningPoint) and EviCore Healthcare (EviCore) to launch new authorizations programs in the coming weeks.
Below you can find the procedure types and codes that will be managed through these programs.
Resources & Trainings for TurningPoint Authorization Programs
New cardiology and MSK authorization programs are set to launch with TurningPoint for dates of service on Sept. 1, 2024 and after. Starting August 20, you'll have the opportunity to test the new authorizations submission process. You’ll initiate authorization request in our provider portal, prism, as you do now. These requests will then be routed to TurningPoint for review.
Procedures requested for dates of service on and after September 1 will be reviewed against TurningPoint’s clinical criteria. You'll be able to find this criteria in TurningPoint’s portal under the Policies section starting on August 20.
We’ve prepared several training resources and opportunities to help you be successful through this transition.
Genetic Testing, Lab / Pathology, and Pacemaker Coding Policies Now Available
We recently posted the following policies to our Provider Manual. Below are links and a high-level overview of each policy. Please see each policy for specific billing, coding and reimbursement details.
- Background: This policy provides industry standard billing guidance to support correct billing. It includes the applicable medical policy which providers can reference for prior authorization requirements, whether the exact lab test name is required on the claim and documentation requirements that are standard for lab testing.
- Applies to: All plans
- Effective: N/A, providing transparency around existing requirements / expectations
- Description: This policy describes the reimbursement methodology for lab and lab-related services. It outlines billing guidelines for place of services, duplicates, multiple tests per day and diagnosis coding.
- Applies to: All plans
- Effective: N/A, providing transparency around existing requirements / expectations
Reminder to Complete Our CMS-Required D-SNP Model of Care Training
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.
Finalizing 2024 InterQual Criteria Transition
As we announced in May, we updated our authorization tools to 2024 InterQual® criteria on July 15 for the following authorization types:
- Level of care (LOC): Inpatient Rehabilitation
- LOC: Subacute/Skilled nursing facility
- LOC: Home Care Q&A
- LOC: Long-Term Acute Care
- CP: Durable Medical Equipment
- CP: Procedures
- Medicare: Post Acute & Durable Medical Equipment
- Medicare: Procedures
- Behavioral health (BH): Adult and Geriatric Psychiatry
- BH: Child and Adolescent Psychiatry
- BH: Substance Use Disorders
- BH: Services
There was a slight delay in updating two authorization types – Acute Adult and Acute Pediatric – which will transition to 2024 InterQual criteria effective August 5.
Ogivri Will be Added to Medical Benefit Coverage on August 1, Instead of Ontruzant
In May, we communicated that Ontruzant® would be added to medical benefit coverage effective August 1. Merck, the maker of Ontruzant, now plans to remove providers’ purchasing discounts for this drug beginning in quarter 3 of 2024.
To help our members get the care they need with options that are affordable for providers, we’ll no longer be adding Ontruzant to coverage under the medical benefit for commercial group and individual members. For Medicare Advantage members, we'll no longer be removing prior authorization requirements.
Instead, effective August 1, Ogivri® will be added to coverage under the medical benefit with no prior authorization requirements for commercial group and individual members, and we’ll remove prior authorization requirements for Ogivri for our Medicare Advantage members.
Provider Trainings for EviCore's Radiation Oncology Authorizations Program
Join EviCore to learn about the new radiation oncology authorization program set to launch this September, as well as how to navigate and successfully request authorizations through EviCore.
Registration is now available for the following dates / times:
- Sept. 3, 2024 @ 1 p.m. ET
- Sept. 5, 2024 @ 11 a.m. ET
- Sept. 10, 2024 @ 1 p.m. ET
- Sept. 17, 2024 @ 1 p.m. ET
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