We're Working to Resolve Some Vaccine Claims Denying Incorrectly
We recently experienced two issues with vaccine codes denying when they shouldn’t:

• Flu vaccine CPT codes 90656, 90658 and 90661 denied incorrectly for children under 4 years of age when they’re available for those ages 6 months and older.
• Some vaccine codes (90476-90759, A4641-A4642, A9500-A9800, B4034-B9999 and Q9950-Q9983) have been denying for Medicaid members for missing or invalid NDC when they shouldn’t.

The issues impact claims with dates of service on or after Aug. 1, 2024.

There’s nothing you need to do. We’re currently working to correct the system error and reprocess impacted claims.

The issue with flu vaccines and age limit has been corrected. A correction for the issue with vaccine codes denying for missing / invalid NDC is expected to be in place on Nov. 24, 2024.

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.

2025 Commercial Fee Schedules Are Available Online
Fee schedules effective January 2025 are now available online for all commercial plans (login required).

Commercial, Individual, and Medicare Formulary Changes Coming Jan. 1, 2025
In January and July of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial, individual and Medicare formularies to align with industry and regulatory changes and to ensure our members have access to safe and effective drugs.

A Look at Our 2025 Disease Burden Management Program
We’ve used data from our 2024 Disease Burden Management Program (DBM) and feedback collected from our ACN partners and providers to build our 2025 DBM Program. Here’s a look at what’s coming.

What’s new for 2025 DBM?
In 2025, we’re adding two new incentives to the program.

• The Clinical Suspecting Incentive: This incentive offers ACNs $2,500 per line of business if they can demonstrate the use of clinical suspecting for their eligible ACA and Medicare Advantage patients.
• The Coding Accuracy Incentive: This incentive offers ACNs $0.50 PMPM (per member, per month) if they achieve a coding accuracy score of 95% or greater in the documentation they submit for their eligible Medicare Advantage patients.

What’s staying the same?
All administrative details, requirements, and incentives from the 2024 DBM program will carry over into 2025.

Want an in-depth review of 2025 DBM?
Check out our 2025 DBM webinar, located on the DBM webpage (behind login) and keep an eye out for the 2025 DBM Program manual, which will be released in December at the same time as our final PCP Incentive Program (PIP) manual.

New Medicare Prescription Payment Plan Coming Jan. 1, 2025
In alignment with Inflation Reduction Act (IRA) requirements, the new Medicare Prescription Payment Plan (M3P) launches on Jan. 1, 2025.

2025 Product Guide for Providers is Now Available 
We have a number of product changes taking effect on Jan. 1, 2025. To inform you about these updates taking effect across lines of business—commercial group, individual and Medicare—we’ve created a 2025 Product Guide for Providers. 

TurningPoint Authorizations: Resources & Information to Support You
Earlier this fall, we launched our cardiac and MSK authorizations programs with TurningPoint to support our shared goals of improved safety, quality and affordability for our members, your patients. Nearly 6,000 cases (18% cardiac / 62% ortho / 20% spine) have been managed since the program’s soft launch in August.

Understanding Disallow Code OX6 on Your Remittance Advice
It’s important to us that you understand the way your claims are handled – including what the various codes that may appear on your remittance advice mean.

One claim adjustment code we get a lot of questions about is OX6.

What’s OX6?
OX6 is a disallow code applied to charges billed in error. This code is:

• Applied to an original claim when a provider submits a replacement or void claim
• Seen on the paper remittance advice for the original claim

Can you appeal OX6?
No, you can’t appeal the OX6 disallow code on the original claim. Instead, review the replacement claim in prism to determine if an appeal is necessary. If it is, you can follow the reviews / appeals process on the replacement claim.

To review a claim in prism:

1. Log into your prism account.
2. Under the Claims tab click Medical Claims.
3. Find the claim in question on the claims listing page. You can use the search bar in prism to enter your Claim ID or any element on the claims list page to filter your claims. When you find the right claim, click on the Claim ID link.
4. Review the resulting claim detail page where you can see line-by-line details for how your claim was processed.

To request reconsideration on the replacement claim, your first step is to submit an informal claim review. Learn how (this process is the same for all plans).

Prism Update: Simplifying Provider Changes
We’re working to simplify submitting provider changes in prism.

Currently, to submit provider changes to us, you must download and complete a PDF form from prism. Over the next several weeks, we’ll phase out this form and embed the form’s questions directly into prism.

Phase 1 changes
In this first phase, the following provider change request types will be embedded in prism and will include the following updates:

• W9, roster and review provider setup requests: These request types will include additional questions that are more specific and detailed to the inquiry type.
• Terminations: The two current request type selections (Term Existing Provider – Group and Term Existing Provider – Individual) will be combined into one request type: Terminations. Providers will then be prompted to select the type of termination – Primary Care Provider, Non-Primary Care Provider or Group/Facility.

These changes are slated to take place by the end of the month.

Coming soon
The remaining provider change request types will still require the PDF form for the time being and will be embedded into prism during a future update.

New and Updated Billing Policies Are Now Available
We’ve posted several new and updated billing policies, which align to industry standards, to the Provider Manual.

Policy going into effect Jan. 1, 2025
The following policy will go into effect on Jan. 1, 2025:

Durable Medical Equipment (DME) place of service (POS) 
We’ll require DME claims for commercial plans to be coded with the POS where the member will primarily use the DME item. This aligns with the DME POS requirement already in place for Medicare plans and established by CMS.

Additional policy updates
Additionally, the following policies were recently posted to or updated in this Provider Manual's billing / coding policies page. They put our current policies and requirements into writing for transparency. Please see the individual policies for details:

• Chronic pain care management services
• Clinical trials
• High tech radiology services
• Home infusion
• Infusion services supplies

READ MORE 

IV Fluid Shortage: Temporarily Allowing Subcutaneous Administration
We understand the significant challenges the recent IV fluid shortage has caused, and we want to ensure as little disruption to care for our members, your patients, as possible.

We’ll temporarily allow inpatient and outpatient facilities to administer subcutaneous fluids (CPT codes 96372 and 96373) in lieu of IV fluids (CPT codes 96360 and 96361), at the frequency / volume needed, from Oct. 1 to Nov. 1, at this point we’ll reassess the need.

To support this effort, we’ve:

• Adjusted the frequency edits for subcutaneous fluids CPT codes (96372 and 96373), as we anticipate more units than typical may need to be administered to achieve the same fluid volume that would be achieved through IV administration.
• Paused the IV fluid notification requirement for inpatient authorizations.
• Informed our post-pay audit vendors of this exception to avoid unnecessary claim audits.

Medicaid Formulary Changes Coming Nov. 1, 2024
The Michigan Department of Health and Human Services (MDHHS) works with its health plan partners to create a list of drugs that all Medicaid health plans must cover. This list is called the Medicaid Health Plan Common Formulary. The formulary is reviewed each quarter by MDHHS’s Common Formulary Workgroup. The following changes will take effect on Nov. 1, 2024, for your Priority Health Medicaid patients.

At-Home Test Kits For Your Priority Health Medicare Patients
Our annual campaign to close care gaps is underway and will run through the end of 2024. This year, we’re working with both Let’s Get Checked (LGC) and Exact Sciences to target Priority Health Medicare members who have a gap(s) in care for: 

• A kidney health screening - Let’s Get Checked
• An HbA1c (hemoglobin A1c) screening - Let’s Get Checked
• A colorectal cancer screening - Exact Sciences

How does the campaign work?

Let’s Get Checked

• LGC will mail your eligible patients a free, at-home test kit to complete and return. All shipping costs are covered by Priority Health.
• After the patient returns their test kit, LGC will send results via mail to both the patient and their attributed PCP. If lab results are abnormal or out of range, they’ll also attempt to reach the patient by phone.
• We’ll send ACNs weekly reports of their patients’ results via secure email.

Exact Sciences
This year, our colorectal cancer screening campaign will be opt-in only for ACNs. If you’re interested in your Priority Health Medicare patients receiving at-home Cologuard® test kits, contact your Provider Strategy and Solutions Consultant. 

Test kits returned to Let's Get Checked and Exact Sciences by December 31 will count toward 2024 PCP Incentive Program (PIP) measure compliance.

Here is a flyer summarizing our LGC and Exact Sciences campaign.

Delayed Implementation for Varicose Vein Authorizations
As we shared in August, we’ll soon require prior authorization following InterQual® criteria for certain varicose vein procedures (see medical policy #91326 [file download] for a list of applicable procedures / services).

Implementation of this requirement, originally slated for Nov. 1, will be delayed. The new implementation dates by plan type are as follows:

• Commercial: Jan. 1, 2025
• Medicaid: Jan. 1, 2025
• Medicare: 2026

Reminder: Our Technical Denials Policy, Submit Outstanding Medical Record Requests
As a reminder, when you receive a claim audit with a request for medical records, it’s important to comply within the allowed timeframe. In alignment with industry standards, we apply technical denials to audited claims when we don’t receive the requested medical records. We’ll begin applying these denials to in-network providers’ claims on Dec. 29, 2024.

Technical denials: definition, timeline, outcome
A technical denial is an administrative claim denial issued when a provider doesn’t respond to requests for medical records.

When a paid claim is identified through audit as requiring medical record review, providers receive three requests to submit medical records. These letters include a list of the requested medical records and instructions for submission and state the claim will be denied if they don’t submit the requested records within 45 days of notice.

If the medical records aren’t submitted by the deadline, we deny the paid claim to provider liability and take back the paid funds. The claim may show a denial code which indicates additional documents are required.

Extension for current, outstanding medical record requests
As we approach the end of the year, we’d like to offer an extension on all current, outstanding medical record requests on audited claims. Please submit medical records by Dec. 29, 2024.

After a technical denial
Even after a technical denial is issued, you can submit the requested medical records to the requestor for consideration.

For funds recoupment, follow our corrections to overpayments process, or we’ll recoup from future claims payments.

Reminder: Provider-Based Billing Policy Went Into Effect June 1
As we shared in April, to better align with industry standards, we updated our provider-based billing reimbursement practices.

What changed?
Effective June 1, we no longer separately reimburse for clinic fees, or any other fees associated with space used to provide E/M services, when billed on a UB-04 facility claim, regardless of the office being located on the hospital campus and/or using the hospital TIN.

This update applies to all commercial lines of business for in- and out-of-network providers and facilities (excluding RHC and FQHC), regardless of reimbursement methodology.

What do you need to know?
Review our provider-based billing policy for details, including:

• What’s included in both non-facility and facility reimbursement rates
• How these rates apply to a claim based on the place of service (POS) code
• The conditions under which a claim will be denied

You should continue to bill the most appropriate place of service (POS) code for services rendered in your practice setting.