10/16/2023
Priority Health Update
Priority Health Managed Care Committee Member
Flora Werle - Cancer & Hematology Centers of West Michigan
We value the care you provide our members and strive to reimburse you accurately and fairly for that care. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently.
On December 5, we’ll implement the new clinical edit noted below and outlined in detail in our Recent & upcoming edits for professional claims PDF. Bookmark this link to always have the most updated list.
Telehealth Services: New vs Existing Patients
Telehealth services shouldn’t be coded for new patients when the code description is specific to established patients.
Additional information on our clinical edits policy is available online.
New RSV vaccine and monoclonal antibody coverage
As we approach the 2023 RSV season, we’re aligning with the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendation to cover the new Arexvy and Abrysvo vaccines as well as the new Beyfortus monoclonal antibody treatment under our members’ preventive benefit.
Claims temporarily denying incorrectly following CMS update
On September 14, CMS withdrew its National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits for the following code pairs (explanation below):
- Column One: 80305, 80306, 80307 (presumptive drug tests)
- Column Two: G0480, G0481, G0482, G0483, G0659 (definitive drug tests)
CMS turned on these edits on July 1, and we updated our systems to comply, applying the edits to facility and professional claims across all lines of business.
To align with this latest update, we’re now in the process of creating a workaround to allow claims to pay appropriately.
What are NCCI PTP edits?
NCCI PTP edits prevent inappropriate payment of services that shouldn’t be reported together.
Each edit has CPT/HCPCS codes in Column One and Column Two. If a provider reports the two codes of an edit pair for the same member on the same date of service (DOS), the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.
What’s the solution timeline & provider impact?
We anticipate having a solution in place in early October. Once that happens, we’ll automatically reprocess impacted claims back to July 1.
There’s no need for providers to resubmit.
In the meantime, providers will continue to see claim denials for the Column Two codes when billed with Column One codes for the same member on the same DOS.
New clinical edits for professional claims go into effect November 26
We value the care you provide our members and strive to reimburse you accurately and fairly for that care. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently.
On November 26, we’ll implement the new clinical edits listed below and outlined in detail in our Recent & upcoming edits for professional claims PDF. Bookmark this link to always have the most updated list.
Humira coverage ends for commercial members on Dec. 31, 2023
To maintain our commitment to providing our members with the most effective therapies at the lowest possible cost, Humira coverage will end for our commercial group and individual members on Dec. 31, 2023. This includes both new-start and existing prescriptions.
Humira will remain on the Medicare formulary, with prior authorization requirements, through 2024.
Effective Oct. 1, 2023, coverage for the Humira biosimilars, Hadlima and Adalimumab-adaz (manufactured by Sandoz) was added to our Medicare, commercial and individual member formularies.
How will this impact providers?
Members will need a new prescription to transition to Hadlima or Adalimumab-adaz.
Medicare members with existing prescriptions for Humira will continue through 2024.
To avoid interruptions in their Tumor Necrosis Factor (TNF) inhibitor therapy, members are encouraged to speak with their providers about whether transitioning to Hadlima or Adalimumab-adaz is right for them.
Thank you for partnering with us in our commitment to providing affordable and effective therapies to your patients, our members.
Provider enrollments error occurring in prism
We’ve discovered an error in provider enrollment submissions through prism; fix coming Tuesday
10/12/2023
Providers with multiple group affiliations and locations who’ve submitted an individual or group provider enrollment in prism after October 2, will show under the incorrect provider group in prism.
What we’re doing
We’ve identified the root cause and will have it fixed by Tuesday, Oct. 17.
What you need to do
We’ll continue to process enrollments that were submitted after Oct. 2. In the meantime, please do not submit any new individual or provider group enrollments until Tuesday, October 17.
We sincerely apologize for the inconvenience this may cause.
Questions? Contact Provider Services at 800.942.3765.
Click here to visit the Priority Health Provider News Page for additional updates.