Complete Story
09/11/2024
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.
2024 DBM Preliminary Payments Were Mailed
Preliminary payments for the 2024 Disease Burden Management (DBM) Program went out in August. Settlements were issued via paper check and mailed to eligible ACNs.
Who received a preliminary payment?
As part of the DBM program’s PCP Visits incentive, ACNs participating in the DBM program with providers who saw 70% or more of their attributed patients by May 31, 2024, earned a preliminary payment. See the DBM Program Manual for more information.
Interested in learning more about how to be successful in the DBM program? Contact your Risk Adjustment Specialist or your Provider Strategies and Solutions Consultant to schedule a meeting.
Peer-to-Peer Policy Update Delayed for Inpatient Procedures
In June, we announced an update to our peer-to-peer (P2P) policy. The update would only allow the clinical information submitted with the initial authorization request to be considered at the P2P. This was slated to go into effect for inpatient procedures on September 4 and outpatient procedures on October 9.
Implementation of this update for inpatient requests is delayed.
A new implementation date hasn’t yet been determined. As always, we’ll keep you informed of any updates as they’re available.
Updated 2024 HEDIS Provider Reference Guide
We recently updated our 2024 HEDIS Provider Reference Guide (login required).
To access the manual, after logging into your prism account, click, "Quality Improvement". You can then bookmark the manual URL in your browser for quick access.
Here’s a summary of the changes.
Page 32: Glycemic Status Assessment for Patients with Diabetes (GSD) measure
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Added clarification on how to interpret the rate for this measure: We added a note stating that, because the rate for this measure is inverted, a lower rate reflects higher performance.
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Updated numerator compliance: The numerator compliance section was updated to state that glycemic status must be ≤9% to show evidence of control.
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Corrected required exclusions: The required exclusions section was corrected due to inaccurate information.
Page 39: Kidney Health Evaluation for Patients with Diabetes (KED)
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Corrected test, service or procedure to close care opportunity: The test, service or procedure to close care opportunity section was corrected due to inaccurate information.
Page 202: Colorectal Cancer Screening (COL-E)
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Updated billing codes
Updated 2024 PIP Manual Now Available
We recently updated our 2024 PCP Incentive Program (PIP) manual (login required).
To access the manual after logging into your account through the link provided, click, "PCP Incentive Program" in the menu then click the, "Get the 2024 PIP Manual" button. You can then bookmark the manual URL in your browser for quick access.
Here’s a summary of the changes:
Administrative details (pg. 7)
Under the ACN payment rules section, we clarified that discrepancies with settlement payments must be brought to Priority Health’s attention within two weeks of the ACN receiving settlement reporting.
Care management (pg. 15)
We expanded our definition of the staff who can provide care management services under the supervision of a PCP. This change aligns with industry standards and will make it easier for ACNs to meet the CM measure’s requirements.
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Qualified Health Professional (QHP) definition and licensure requirements have been removed.
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Initial and continuing education requirements are still required for clinic staff on the care team who are providing care management services.
Reminder: Radiation Oncology Authorization Program With EviCore Launches September 15
Our radiation oncology authorizations program with EviCore, first announced in June, will launch on September 15. On that date, authorization requests initiated in prism for impacted codes performed in an outpatient setting will be automatically redirected to EviCore’s provider portal to complete the request.
Be sure to check if you have treatments already scheduled that will now require authorization. Review the impacted code lists to see which services and procedures will be managed by EviCore on our members’ behalf. Bolded codes are those that don’t currently require authorization but will for dates of service on / after September 15.
Below is an FAQ to support your success:
Question: How do you submit an authorization through EviCore?
Answer: Our provider portal, prism, will automatically redirect you to EviCore to complete authorization requests when appropriate – no separate login needed. Find step-by-step instructions in our provider training slides.
Question: What if you’ve already submitted a request through GuidingCare?
Answer: If you’ve already submitted an authorization request to Priority Health through GuidingCare, there’s no need to resubmit through EviCore. Your existing authorization request will be honored.
Question: What if your patient is undergoing treatment when this authorization program goes live on September 15?
Answer: We’ll honor all radiation oncology courses of treatment that are in progress as of EviCore’s management, effective Sept. 15, 2024. Modifications to existing authorizations, such as date extensions, are managed through Priority Health. Contact Priority Health to determine if an authorization for the services underway is already on file.
Question: What if there’s a change in the approved treatment plan (such as adding IGRT or additional treatments)?
Answer: An authorization is only valid for the treatment plan requested. A new medical necessity determination is needed for any new or modified treatment plans. If you need to change the plan during the course of treatment, contact EviCore. It’s strongly recommended to call EviCore as soon as it is known there is a change in treatment plan and prior to billing for the corresponding services.
Question: Are provider trainings available?
Answer: Yes! EviCore has hosted four provider training webinars. A copy of the presentation will be made available online at evicore.com/resources/healthplan/priority-health for those unable to attend live.
Question: Where can you find additional information?
Answer: Below you can find links to additional information to help you and your providers be successful through this transition:
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Provider training webinar slides – including an overview of the program, how to submit requests and contact information in case you have questions
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Provider FAQs – answers common questions about EviCore
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Impacted procedure codes – lists the procedures that will be managed by EviCore when performed in an outpatient setting starting September 15
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Clinical guidelines – search for Priority Health to find applicable clinical guidelines. Before September 15, click the Future tab to access the guidelines.
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