Complete Story
01/20/2025
Priority Health Update
Priority Health Managed Care Committee Member
Flora Werle - The Cancer & Hematology Centers
Click here to visit the Priority Health Provider News Page for additional updates.
Telemedicine / Virtual Services Billing Updates Effective Jan. 1, 2025
At Priority Health, we align our telehealth / virtual services billing guidelines with AMA, CMS and MDHHS. AMA and CMS recently released updates effective Jan. 1, 2025. Please see below how these updates apply to our plans:
New CPT telehealth codes for commercial plans
AMA introduced new telehealth-specific codes (98000-98016) effective Jan. 1, 2025. We’ll cover these codes for our commercial plans, in addition to the regular evaluation and management (E/M) codes.
The new codes are outlined in our medical policy #91604 – Telemedicine / Virtual Services. Continue to follow the billing guidance available here.
Note: Medicare doesn’t recognize these new codes, and so we aren’t covering them for our Medicare plans. Additionally, Medicaid hasn’t yet issued a 2025 fee schedule – we’ll continue to follow Medicaid’s guidelines as they’re released.
Extension to PHE telehealth flexibilities
Congress extended the COVID-19 public health emergency (PHE) telehealth flexibilities that were in place for Medicare plans through Mar. 2025. We’ll apply this extension to our Medicare plans as well.
These flexibilities loosened geographic and location restrictions on where services could be provided, and loosened limitations on the scope of practitioners who can provide telehealth services. See CMS’s MLN Matters article MM13887 for more details.
Register Now For Our January 30 Billing & Coding Webinar
Join us for our first billing & coding webinar of 2025 to learn about:
- Navigating our Provider Manual & helpful resources
- Understand how your claim processed and why, right in prism
- Most common clinical edits we see applied to claims
- Asking a question about or disputing a clinical edit
- Submitting corrected claims
- 2025 telehealth billing updates
Can’t join us?
All webinars are recorded and posted to our website within a week of the event, so you can watch at your convenience.
Reminder: HMA Members Have Access to Priority Health’s Network
Priority Health launched a new product on Jan. 1, 2025, called HMA. HMA is a third-party administrator (TPA) product, but HMA plan members have access to Priority Health's PPO network.* Make sure you accept this health plan, as you would with any Priority Health plan.
New & Updated Billing Policies are Now Available
We publish billing policies to offer transparency and help providers bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
The following billing policies were recently published to or updated in our Provider Manual. These policies reflect our current requirements / system set up – they don’t change the way you work with us or how you’re reimbursed.
Note: If a policy is listed as a revision, the changes made are detailed on the last page of the policy.
Reminder: Corrected Claims Must Include the Original Claim ID
As a reminder, we require that corrected claims – submitted to either replace, correct or void an original claim that was partially or fully paid – include the original claim ID. We’ll soon begin front-end rejecting corrected claims that have an invalid / incorrect original claim ID. This will apply to both facility and professional claims for all plan types.
Note: For claims that were fully denied, providers should submit a new claim rather than a corrected claim. This update doesn’t impact this process.
Submitting corrected claims
If you’ve made a mistake on a claim submitted to us and would like to either correct, replace or void it, you can do so by submitting a corrected claim. Per our Provider Manual, the corrected claim must include the following elements:
- Appropriate frequency type code: 7 for correction or 8 for void
- Original claim ID number
Instructions are available in our Provider Manual for submitting corrected claims for both facility / UB-04 and professional / CMS-1500 claims. Ensure the original claim ID included in the required corrected claim field is correct to avoid a front-end rejection.
Non-Urgent Inpatient Hospital Transfers Will Require Prior Authorization Effective Mar. 10, 2025
When a member is receiving non-urgent inpatient care, we’ll soon require prior authorization before their care can be transferred to a different facility. This change will go into effect Mar. 10, 2025, and won’t impact urgent / emergent hospital transfers.
Note: The transfer of a member’s care between facilities is separate from ambulance transportation. An additional authorization request may be needed for the transportation service, depending on the type of transportation – see below for more.
How to submit a hospital transfer request
Either the transferring or receiving facility should submit a new Acute / Emergent authorization request through GuidingCare and include the following information:
- Reason for the transfer
- Accepting attending physician name at the receiving facility
- Other facilities considered if the transfer is out-of-network for the member’s benefit
- Relevant clinical information
- Anticipated mode of transportation
The facility can ask for expedited review after submitting their authorization request in GuidingCare by calling:
- During business hours: Call our provider helpline at 1.800.942.4765.
- After business hours: Call our Utilization Management team directly at 1.800.269.1260.
Report Broken Links
Have you encountered a problem with a URL (link) on this page not working or displaying an error message? Help us fix it!
