05/13/2024
Priority Health Update
Priority Health Managed Care Committee Member
Flora Werle - Cancer & Hematology Centers of West Michigan
Click here to visit the Priority Health Provider News Page for additional updates.
We're Working to Resolve Medicaid Claims Being Rejected Incorrectly
We’re experiencing an issue with some Medicaid claims front-end rejecting for “Referring / Ordering / Attending is not Enrollment Type 1 / Individual” when they shouldn’t. This issue started on February 22. The edit is being applied incorrectly in some cases because it’s checking claims for the provider’s enrollment type and business status when it should only be checking enrollment type.
Our teams are working diligently to resolve this issue.
- In-state / in-network providers: Claims incorrectly rejected for this edit would still have been rejected due to inactive CHAMPS status on the date of service. Please check your CHAMPS status.
- Out-of-state providers: There’s no need to rebill. Impacted claims will be reprocessed for payment automatically when the issue is fixed. We’d also encourage you to check your CHAMPS active status, as it may impact how this edit applies to your claims.
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.
Formulary Changes for Commercial Group and Individual Members Coming July 1
In January and July of each year, the Priority Health Pharmacy and Therapeutics committee make changes to the commercial group and individual formularies to ensure our members have access to safe, effective and affordable drugs.
Commercial group and individual formulary changes take effect on July 1, 2024
Beginning July 1, 2024, 13 drugs will be removed from our commercial group formulary and 1 drug will be added to our site-of-service policy. These changes will impact 95 of our commercial group and individual members.
PriceMyMeds Launched on April 25 to Increase Prescription Drug Affordability
Beginning April 25, 2024, we’re offering a new pharmacy program called PriceMyMeds to our commercial (group and individual) members. PriceMyMeds helps members save on prescription medications by automatically finding the best price for a prescription at nearby in-network pharmacies.
This new benefit is a key part of our ongoing goal to better support our members in getting the care they need by making sure prescription drug costs are not a barrier to the care you provide.
How does PriceMyMeds work?
When a member’s prescription is filled at a pharmacy, PriceMyMeds automatically searches for and applies savings opportunities, when applicable. Members will also have access to the PriceMyMeds app, allowing them to sign up to receive alerts when greater savings opportunities are available at other pharmacies in the area. When members use the PriceMyMeds app to locate a better price at an alternative pharmacy, PriceMyMeds will provide instructions on how to 1) ask for a price match or 2) work with their pharmacist to complete a prescription transfer.
Check out our provider manual for more details.
We’re No Longer Allowing Providers to be Enrolled Under Multiple ACN Contracts With the Same NPI, TIN and Address.
Effective July 8, 2024, we’ll no longer allow providers to be enrolled under more than one ACN contract at a time under the same NPI, TIN and address. This includes ACNs with both direct and delegated contracts.
Background
ACNs enroll their providers with Priority Health through prism (direct) or through a SharePoint submission process (delegated). If an ACN is requesting to enroll a provider that's still enrolled with another ACN, we have been leaving the provider enrolled under the original ACN’s contract, adding the new ACN enrollment as an alternate and sending a letter to request the provider update their enrollment with us.
Reminder to Complete Our CMS-Required D-SNP Model of Care Training
Providers play an integral role in the care teams that support our dual-eligible special needs (D-SNP) members. That's why the Centers for Medicare and Medicaid Services (CMS) requires us to make sure providers who are contracted with us to see PriorityMedicare patients are trained on our Model of Care.
Our Model of Care is a quality improvement tool that ensures the unique needs of our D-SNP members are met and describes the processes and systems we use to coordinate their care.
Make Sure to Include a Refund Form With Your Overpayment Checks
When sending a refund check to us for an overpayment, it’s important that you also include a completed refund form. This completed form allows us to apply the refund to the correct claim overpayment.
When are refund checks necessary?
We’ll send a letter requesting repayment in the following cases*:
- Professional providers: $200+ overpayment
- Facility providers: $5,000+ overpayment
This letter is the only form of notification your office will receive. You’ll then receive a monthly statement of any outstanding overpayments until the overpayment is settled and no longer has a balance due.
For overpayments less than the amounts listed above, we’ll make the necessary corrections and adjustments on a future remittance advice.
*Occasionally, we may make necessary adjustments automatically even if the overpayment amount exceeds the refund check threshold (i.e., in the event we need to reprocess claims for multiple providers due to an error).
Where can you find the refund form?
Click here to download a fillable and printable refund form (also available here in our Provider Manual). Complete this form, explaining the reason for the refund, and mail it in with your check to:
Priority Health
Attn: Overpayment Refunds
1705 Reliable Parkway
Chicago, IL 60686
Find more information
Find additional details, including timelines for recovering overpayments, in the Corrections to payments section of our Provider Manual.
New and Recently Updated Billing / Coding Policies
The following billing / coding policies were recently updated or newly posted to our Provider Manual.
Change Healthcare Update: Electronic RAs Resumed Through Change Healthcare and Optum Clearinghouses; All Services Should be Resumed
Electronic remittance advices turned back on this week
If you’re set up to receive electronic remittance advices (ERAs) through Change Healthcare or Optum, you should have received files from February, March and April starting the week of April 29.
All services restored; contact your clearinghouse if you’re not able to submit claims
Claims we receive continue to process as normal. We’re receiving claims from all clearinghouses we work with. If you’re still having issues submitting claims, contact your clearinghouse.
Paper checks
Paper checks and paper remittance advices continue to send through a manual process. Please keep your check stubs so you’re able to match the check reference ID number to your RA when it arrives separately in the mail.
Change Healthcare communications archive
Visit the News & education page in our Provider Manual for an archive of communications we've sent about the Change Healthcare outage.