06/14/2024
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.
SaveOnSP Ended on May 31 for Select Commercial Members
SaveOnSP, a service that helps participating members find and enroll in manufacturer copay assistance programs for discounts on their specialty prescription drugs (Tier 4 and 5), ended on May 31 for small business commercial groups and individual members.
Why did SaveOnSP end?
Recently, the Centers for Medicare and Medicaid Services (CMS) released a new rule classifying all health plan covered drugs as essential health benefits (EHB). Prior to this, only drugs that met a specific benchmark could be considered EHB. Because SaveOnSP focused solely on securing copay assistance for non-EHB drugs, the program is no longer applicable to the impacted members.
Can members still get manufacturer copay assistance?
Yes. Manufacturer copay assistance may still be available through the drug manufacturer; however, members must enroll on their own.
How does this impact our members?
Members must either manage their own enrollment in available manufacturer assistance programs or pay the cost share for their prescriptions.
May 2024 Medical Policy Updates
Our Medical Advisory Committee (MAC), comprised of network physicians contracted with Priority Health, met in May and approved the medical policy updates described below.
Unless otherwise noted, the following updates will go into effect on June 1, 2024.
New medical policy
Computer Assisted Surgical Navigation (#91641)
This policy was developed to address the surge of computer assisted surgical (CAS) navigation technologies. The policy currently only addresses CAS navigation bronchoscopy, and the medical criteria follow National Comprehensive Cancer Network non-small cell lung cancer guidelines. The policy does not change existing coverage.
Coverage change
Experimental/Investigational/ Unproven Care/Benefit Exceptions (#91117)
Effective July 1, 2024, two codes for temporary prostatic stents (C9769 and 53855) will no longer be covered for Commercial and Medicaid lines of business.
Action for Prism Security Administrators: Mandatory Annual pSA Renewal Process Begins June 1
Our annual prism Security Administrator (pSA) renewal period begins on June 1. pSAs will have until Aug. 1 to review and either approve or deny all user affiliations for your group or facility.
What exactly is happening?
Each provider group and/or facility needs a pSA to control access to data like claims, authorizations and appeals. pSAs control access by approving or denying affiliation requests. During this annual pSA renewal period, pSAs review affiliation requests they’ve already approved to make sure each user’s access is still needed.
If a user’s affiliation is renewed by their pSA, nothing will change for that user. If a user’s affiliation is denied, that user will lose access to all of that group or facility’s data.
Important: If users aren’t renewed, they'll automatically be removed from the provider affiliation after Aug. 1. It’s important for pSAs to review all renewals and take action to ensure access isn’t disrupted.
Aligning Commercial DME Coding / Billing Guidelines With CMS Effective Aug. 1, 2024
We’re aligning our commercial billing and coding requirements for durable medical equipment (DME) supplies to those defined by the Centers for Medicare and Medicaid Services (CMS).
The following policies – which establish reimbursable limits / frequency guidelines pulled directly from CMS local coverage determinations (LCD) and coding articles – will go into effect on Aug. 1, 2024:
Exceptions & appeals
Any exceptions to these policies will be specifically outlined in our Provider Manual or in our commercial medical policies. Providers may appeal denials for units exceeding the defined limits – appeals must be supported with medical record documentation.
Medicare & Medicaid
For Medicare claims, we’ll continue to follow CMS-defined guidelines as outlined by the Medical Affairs Committee (MAC) in national coverage determinations (NCD), LCD and Articles. Our Medicaid products will continue to follow MDHHS- and CHAMPS-defined guidelines.
See our Provider Manual’s payment policies page and continue to monitor these PriorityActions emails for additional policy alignment information.
Inpatient Peer-to-Peer Policy Update Coming Sept. 4, 2024
Effective Sept. 4, 2024, and in alignment with industry standards, inpatient peer-to-peer reviews (P2P) will only consider the clinical information submitted with the initial authorization request. We’ll classify any additional information submitted after the initial denial as a level 1 appeal and cancel the P2P request.
As a reminder, we offer two levels of appeal for medical authorization denials.
Be thorough with inpatient authorization requests
We recognize that, when admitting a patient to the hospital, you may need multiple days to appropriately assess and document their condition and care plan. This is why we don’t require you to notify us within 24 hours if one of our members is hospitalized. Additionally, we don’t require authorization for observation stays regardless of the length of hospitalization.
By ensuring all supporting documentation is available and submitted with the initial authorization request, you can avoid potential re-work and appeals. We’re seeking to work with you, our providers, in getting you the best decision the first time.
Get more information
Review our full P2P policy for additional information, including request timelines, when P2Ps aren’t available, how to request a P2P, and more.
New Radiation Oncology Authorizations Program to Launch This Fall
We’re partnering with EviCore on a new authorization program for outpatient radiation oncology procedures. This new program is slated to launch Sept. 15, 2024.
How will the program work?
You'll initiate the authorization request process in prism, as you do now. When an outpatient radiation oncology procedure requires authorization through EviCore, prism’s Request an Authorization page will automatically redirect you to EviCore’s online authorization portal.
Understanding When to Submit Standard VS Urgent / Expedited Authorization Requests
When submitting authorization requests and deciding whether to submit as standard or expedited, it’s essential to understand the criteria that define urgency.
By default, submit your requests as standard. Overuse of expedited requests can inadvertently lead to delays in review and denial decisions. If a case doesn’t meet the criteria for urgency (see below), submit it as a standard request.
Appropriate use of expedited requests
Expedited requests are reserved for cases that require immediate attention due to potential harm or life-threatening situations. This can include:
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Loss of life or limb: These cases involve imminent risk to life or limb (i.e., severe trauma, acute vascular emergencies, critical organ failure)
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Severe, intractable pain: Instances where patients experience intense, unmanageable pain that demands urgent intervention
Expedited elective inpatient requests
When submitting elective inpatient requests that meet urgent criteria, set your admission type to Elective Procedure and select an expedited authorization priority. Setting the admission type to Emergent inadvertently leads to delays in the review process, as it automatically routes the request to the incorrect Priority Health team.
By adhering to these guidelines, we can ensure an efficient authorization review process and better outcomes for our members, your patients. To learn more, see our GuidingCare Quick Start guide.
Updated 2024 PIP Manual Now Available
We recently updated our 2024 PCP Incentive Program (PIP) manual (login required).
- Submitting exclusions and more to our HEDIS team (Page 11)
- Appendix 2: Guidelines for reporting gap closure (Page 34)
- Appendix 5: Report inventory (Page 41)
Our updated 2024 HEDIS Provider Reference Guide is Now Available
We recently updated our 2024 HEDIS Provider Reference Guide.
To access the guide, log into your prism account and navigate to Provider Incentive Programs, then Quality Improvement. You can then bookmark the manual URL in your browser for quick access.
Here’s a summary of the changes:
- Glycemic Status Assessment for Patients with Diabetes (GSD) measure
- Kidney Health Evaluation for Patients with Diabetes (KED) measure
- Billing codes were updated for the following measures:
Clinical Documentation is Critical For All Authorization Requests, Including Preservice Elective Inpatient Procedures
Submitting properly documented clinical information with your authorization requests ensures accurate evaluation and facilitates effective, timely decision making. Without it, the review process can be significantly delayed or result in a denial.
How to ensure proper clinical documentation with every request
With each request, submit clinical documentation that is:
- Complete: Include clinical notes, test results, imaging reports, and any other pertinent information.
- Relevant: Clinical records must be up-to-date and address the specific criteria outlined for the requested service.
Additionally, we strongly encourage you to include your direct contact information – name and phone number – when submitting requests. This allows us to reach you quickly for any additional information needed during the review process.
Get more information
For additional details on submitting elective inpatient prior authorizations, see our guide. Guides for each authorization type are available through prism, our provider portal:
- Log into your prism account.
- Under the Authorization menu, click Request an Authorization.
- On the resulting page, click Auth requests help page.
We appreciate your commitment to quality care and collaboration. By collectively adhering to these guidelines, we can streamline the review process and provide optimal outcomes for our members, your patients.
Introducing VOA Modules and New 2024 Live VOA Dates
We have two announcements regarding our Virtual Office Advisory (VOA) webinars:
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We’re launching a new educational series called VOA Modules, consisting of short videos available on-demand in our online provider manual.
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We’ve scheduled additional live VOAs for the remainder of 2024, each focused on a single major topic of timely relevance.
Why are we changing the format of VOAs?
You’ve requested more targeted content for our VOAs. We’ve heard you, and we’re now offering VOA Modules and more focused live VOAs in response. Both provide precision-targeted content, so you can watch what you need without having to sit through what you don’t.
Reminder: Follow ICD-10 guidelines and code to the highest degree of specificity
As a reminder, when billing for both professional and facility services, it’s important to code to the highest level of specificity.
At Priority Health, we use several coding and billing resources to align correct coding guidelines for accurate claims processing. This includes criteria defined by ICD-10 coding guidelines. See our General Coding Policy, available on the Billing & coding policies page in our Provider Manual, for details.
Clinical edits are controls aligned with coding guidelines or industry standard principles to flag inappropriate coding practices, inaccurate billing or duplication of services.
Why are we issuing this reminder?
On Aug. 16, 2022, we issued a notice to the provider network for a new clinical edit for ICD-10’s Excludes1 criteria, which details diagnosis codes that shouldn’t be reported together because the two codes can’t occur at the same time.
In October 2022, the edit was turned on for professional claims. On June 4, 2024, we’ll implement the edit for inpatient and outpatient facility claims as well.
What do you need to know?
You can reference the ICD-10 coding manual’s Excludes Notes section for more detail and examples. You may also correct and resubmit denied claims with accurately coded diagnosis codes.