Complete Story
02/17/2025
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.
We're Closing Fax Number 616.975.8856
Effective Feb. 14, 2025, our fax number 616.975.8856 will no longer be operational. A small number of fax inquiries are sent to us at 616.975.8856 currently, however this number doesn’t reach the appropriate teams for the inquires sent.
In-network providers should use prism for all inquiries or disputes. If you don’t have a prism account, you can create one here. If you’d like more information on how to navigate and use prism, see our prism resources webpage and our Get Your Questions Answered document for detailed instructions.
Out-of-network providers are also encouraged to use prism as the fastest method of inquiry and dispute resolution. Out-of-network providers may also call our Provider Helpline at 800.942.4765 with questions.
NCQA's 2025 HEDIS Audit is Underway
Our Healthcare Effectiveness Data and Information Set (HEDIS®) team is contacting select providers by fax and phone to request medical records for the 2025 HEDIS audit. This is an annual audit conducted by the National Committee for Quality Assurance (NCQA) and used to measure quality of care across health care organizations in the United States.
Medicaid Formulary Changes Effective Feb. 1, 2025
As decided by the Michigan Department of Health and Human Services (MDHHS), beginning Feb. 1, 2025, combination use of medications in the following Preferred Drug List (PDL) drug classes won’t be covered under the Medicaid Health Plan Common Formulary:
- Oral Hypoglycemic DPP4 (e.g., Januvia, Tradjenta), Oral Hypoglycemic-Combinations (e.g., Janumet, Jentadueto,)
- Incretin Mimetics (e.g., Byetta, Ozempic, Trulicity, Victoza)
- Anti-Obesity GLP-1s (Saxenda, Wegovy, Zepbound)
What do you need to do?
If you have impacted Medicaid patients, you’ll need to limit their therapy to a single drug from any of the above drug classes. If your patient continues treatment with two or more drugs from any of the above drug classes after February 1, their medication won’t be covered.
How are we communicating this change?
Impacted members and their prescribing providers will receive a letter in the mail detailing these changes and what steps they can take. Members are encouraged to contact their prescribing provider to discuss their treatment plan.
Why the change?
MDHHS works with health plans to create the Medicaid Health Plan Common Formulary - a list of drugs that all Medicaid health plans must cover. This formulary is reviewed quarterly by the Common Formulary Workgroup and the MDHHS fee-for-service (FFS) and Pharmacy and Therapeutics (P&T) Committee.
Questions?
Please review the coverage and criteria information found on our Medicaid formulary page. Pharmacy changes are posted quarterly in the Provider Manual, on our formulary updates page. You can also call us at 800.466.6642. We’re available 8 a.m. to 7 p.m., Monday – Friday and from 8:30 a.m. to 12 p.m. on Saturday.
Updated TurningPoint Provider Training Guide Now Available
We’ve updated the TurningPoint Provider Training Guide to include:
- Additional information requests (all plans)
- Intent to deny calls (Medicare)
- Reconsideration requests (commercial, Medicaid)
We made these updates to offer further transparency into TurningPoint’s processes, and to support you in getting the most accurate determination the first time and, if possible, avoid the appeals process.
As a reminder, TurningPoint manages cardiac and MSK authorizations on our members’ behalf.
Below is a summary of the additions made to the training guide, pages 20-22.
Reminder of Our CPAP & BiPAP Rental Guidelines
We’re sharing a quick reminder of our continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) device capped rental guidelines. We hope these guidelines will support you in managing both authorizations and billing for these rentals for our members.
CPAP and BiPAP device rental management
Three-month trial period – no authorization required
CPAP and BiPAP rentals for all members start with a three-month trial period. No prior authorization is required for this trial, during which the member must demonstrate that they meet continued use compliance. Compliance details are available in medical policy 91333 – Obstructive Sleep Apnea.
Post-trial period – authorization required
After the trial period, authorization for continued use is required, whether or not the member met the compliance criteria.
- Member met compliance: Submit an authorization request for the remainder of the rental cap period (seven additional months for commercial and Medicaid, and 10 additional months for Medicare) with evidence of compliance.
- Member didn’t meet compliance: Submit a retrial authorization request immediately. Retrial requests require a new face-to-face office visit with the member.
CPAP and BiPAP rental authorizations are managed in GuidingCare, accessed through prism’s authorization request form (login required).
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