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03/17/2025

Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga

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
Update: Mar. 19, 2025

Congress has further extended the COVID-19 public health emergency (PHE) flexibilities that were in place for Medicare plans through Sept. 30, 2025. We'll apply this extension to our Medicare plans as well.

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 (file download). 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 Sept. 30, 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.

Updated 2025 PCP Incentive Program (PIP) Manual Now Available
We recently made the following update to the 2025 PCP Incentive Program (PIP) Manual:

Care Management codes (pg. 20-21)
The code table has been corrected to reflect the following:

  1. Claims with codes G9008, 99484 and 98966 will serve to identify Medicare members that have received care management services and will count toward the 2% target. These codes were previously incorrectly unchecked for Medicare.
  2. Code G0512 is valid for the full program year (rather than through June 30, 2025, as previously indicated in the manual).

Access the manual through our Provider Incentives webpage (login required).

Register Now For Our April 17 Billing & Coding Webinar (Including Credentialing & Enrollment Tips)
Join us for our second billing and coding webinar of 2025 to learn about:

  • Credentialing and enrollment tips: How to set up a new group, add a provider to an existing group and update provider information
  • Clinical edits and misused modifiers: The most commonly seen clinical edits and misused modifiers and how to correct these issues and bill appropriately
  • Behavioral health billing: Ensuring your staff is credentialed appropriately, getting authorizations when necessary, coding diagnoses to the highest specificity and more
  • Ambulance billing: Tips and reminders for successful ambulance billing

Register Now 

Can’t join us?
All webinars are recorded and posted to our provider webinars page within a week of the event, so you can watch at your convenience. To access the webinars page, log into prism and select Resources > Training & Opportunities > Webinars.

Pontiac General Hospital is No Longer Part of the Priority Health Network
Pontiac General Hospital in Pontiac, Michigan, is no longer in-network for Priority Health members of any plan type. This change is retroactively effective back to Nov. 24, 2024.

Why was Pontiac General Hospital terminated from our network?
Pontiac General declared bankruptcy after announcing the loss of Medicare funding on Nov. 24, 2024. CMS pulled funding for the hospital after finding it repeatedly out of compliance in multiple areas. Because Pontiac General does not meet quality standards, they're no longer in network.

What is the provider impact of this change?
Do not refer Priority Health members to Pontiac General Hospital, as these members may see higher costs for non-emergency treatment received there. 

Where can you refer Priority Health members instead?
If treatment at a hospital is needed for your patients who are Priority Health members, use the Find a Doctor tool to find in-network providers. Other hospitals in the Pontiac area that remain in-network include:

Manage patient and claims data with prism.

We're Resolving Some Medicaid Claims Rejecting Incorrectly For Missing or Invalid Date of Death
We’re experiencing an issue with some Medicaid claims front-end rejecting for missing or invalid date of death when they shouldn’t. The claims are billed correctly with the appropriate date of death present; however, our system is rejecting them incorrectly.

There’s nothing you need to do. We’re working diligently to correct the issue causing the incorrect rejections. Once the error is fixed, we’ll reprocess all impacted claims for payment.

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.

We're Collecting Medical Records For Our Medicare Retrospective Review
Beginning in the spring, our Risk Adjustment team in partnership with Datavant, a health information technology company, will be contacting select providers to request medical records for our next Medicare retrospective chart review. This review helps us to validate our members’ diagnoses and ensure the risk adjusted payments we receive from the Centers for Medicare and Medicaid Services (CMS) are accurate.

What do you need to do?
If you’re contacted by Priority Health or Datavant, please submit the requested documentation by the deadline provided in your communication.

Submitting documentation
To maximize time and efficiency for your staff and ours, we encourage you to prioritize digital submission methods when sending us medical records, if you’re able. These methods include:

Refer to the communication you receive from Priority Health or Datavant for a full list of submission methods.

Why are we requesting medical records?
CMS requires us to validate diagnoses contained in claims and our members’ medical records, and to submit complete and accurate diagnostic data for each member, each year.

New Member Rewards Supporting Maternal Care for Your Priority Health Medicaid Patients
To help support our members throughout their pregnancies and decrease the risks of low birth weight and long-term health complications in infants, we’re offering new member rewards to your Priority Health Medicaid patients for getting the right care, at the right time. These rewards are available now through Dec. 31, 2025 and include the following:

  • A $20 gift card when a member notifies us of their pregnancy within the first trimester
  • A $30 gift card when a member completes a prenatal visit with a provider within the first trimester
  • A $50 gift card when a member completes a visit with a provider between 7 and 84 days after delivery

Available gift cards may vary.

Want more information?
Check out our member flyer or download our member rewards handout to see a full list of the Medicare and Medicaid member rewards we offer. 

 Get Our 2025 Member Outreach Calendar
Our 2025-member outreach calendar is now available. This resource helps keep you up-to-date on how and when we’re contacting our members to remind them to get the care they need.

What’s included in the calendar?
Our outreach calendar contains helpful information like:

  • Outreach topic/disease burden
  • Outreach description
  • Outreach timing

You can find our member outreach calendar on the Quality Improvement page in prism (behind login).

 

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