10/14/2024
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.
Register Now to Learn About Our 2025 DBM Program on October 29
Join us for a webinar to learn more about the 2025 Disease Burden Management (DBM) program. This session will cover:
Elements from the 2024 DBM program that will carry over into 2025
- What's changing in 2025, including 2 new program incentives
- How to be successful in risk adjustment and the 2025 DBM program
Can’t join us?
All webinars are recorded and posted to our website within a week of the event, so you can watch at your convenience.
National Prescription Drug Take Back Day Coming Oct. 26
We’re pleased to participate again in National Prescription Drug Take Back Day on Saturday, Oct. 26, 2024. We invite your patients and all community members to drop off their expired, unwanted or unneeded prescription medications for safe disposal from 10 a.m. – 2 p.m. at one of the locations listed below.
In West Michigan, we’re partnering with Corewell Health, Kent County Health Department, Pine Rest and Families Against Narcotics to host collections sites at:
Kent County Health Department
700 Fuller Ave. NE, Grand Rapids
Corewell Health Grand Rapids Hospitals Care Center - Cutlerville
(North side of the building)
80 68th St., Grand Rapids
Priority Health
3111 Leonard St. NE, Grand Rapids
New Resource: Understanding Why a Claim is Denied
It’s important to us that you understand the way your claims are handled. That’s why we created a new resource to help you understand exactly why a claim may have been denied and be able to take any appropriate next steps.
Understanding claim denial explanation codes
When a clinical edit applies to a claim, our system adds an explanation code with a brief description of the denial reason to the claim details here in prism. Because these explanation codes are often tied to multiple clinical edits, the descriptions seen in the claim details are broad.
For many clinical edits, you’ll see a “See Edits” button in prism, in addition to the explanation code, that provides additional rationale / possible reasons why the edit was used on the claim. However, for some clinical edits, prism doesn’t offer this level of detail.
This new claim denial explanation codes PDF compiles additional information / rationale for the most common clinical edits that isn’t available in prism.
Get our explanation codes resource.
We've Added Exclusion Criteria to Our SUPD Provider Tipsheet
We’ve updated our HEDIS Statin Use In Persons with Diabetes (SUPD) provider tipsheet to include exclusion criteria and associated billing codes for the SUPD measure.
You can download the provider tipsheet or find it on our Quality Improvement page (login required) in prism.
Have you visited our Quality Improvement page?
You’ll find tips for success in HOS, HEDIS and CAHPS along with downloadable educational resources.
We're Working to Resolve Some Claims Denying Incorrectly For no Anatomical Modifier (Denial Code U54)
We recently experienced a brief issue with CPT, HCPCS and DME codes* that start with a letter (e.g., G0438, H0020, E0955), and which don’t require an anatomical modifier, denying for no anatomical modifier when they shouldn’t.
The issue impacts claims processed between Sept. 24-27, 2024.
There’s nothing you need to do. We’re currently working to reprocess these 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.
*Note: Some codes do require anatomical modifiers and will continue to deny correctly with explanation code u54.
Void Claims Now Appear on Remittance Advice With Original Claims
In June 2024, we changed how we process your void claims (claims submitted to cancel a previous claim) to align with industry standards, for both UB-04 and HCFA-1500 claim forms.
Previously, we would close the void claim, and you would see just one claim adjustment on your remittance advice (RA) for the original claim’s payment recovery. Now, you’ll see adjustments for both the void claim and original claim as follows:
|
RA type |
Adjustment codes you'll see |
|
Paper RA |
Void claim (denial): K49 – Claim has been cancelled or voided Original claim (payment recovery): OX6 – Charge billed in error |
|
Electronic RA |
Void claim (denial): CARC 18 – Exact duplicate claim/service Original claim (payment recovery): CARC 16 (Claim/service lacks information or has submission/billing error(s)) and RARC M79 (Missing/incomplete/invalid charge) |
Please note, we won’t process appeals on void claim denials.
Starting Dec. 9, Submit New or Corrected Claims When You Get a Retroactive Authorization After a Claim Denial
There will soon be a new requirement for claims processing when a retroactive authorization has been granted after a claim denial.
What’s changing?
Starting Dec. 9, 2024, we’ll require you to submit a claim for payment if a retroactive authorization is approved after a claim has denied (fully or partially) for no authorization:
- Claim denied in full—submit a new claim
- Claim partially denied—submit a corrected claim with the authorization number listed in the notes section
What’s not changing?
Our medical authorization appeals process isn’t changing. If you appeal a denied authorization request and we grant a retroactive authorization during this appeals process, there’s no need to submit a new claim if a claim had previously been denied. Our teams will continue to reprocess these denied claims for payment automatically.
Prism Update: Simplifying EFT Setup
Soon, we’ll simplify our electronic funds transfer (EFT) setup process in prism, making it easier for us to work together on your EFT setup and management needs.
What’s changing?
This month, our electronic funds transfer (EFT) setup form will be moved from prism’s Resources menu to the General Requests section. The form fields and information requested will remain the same but will look a little different.
Why are we making this change?
The current EFT setup form takes you outside of prism to complete your request, and we communicate with you via email.
With this update, all EFT setup requests will create a prism inquiry, allowing you to submit, track and receive our updates on your requests directly in prism. No separate form or emails required.
End of Year Record Requests Are Underway
Through the end of 2024, our Risk Adjustment team will contact select providers via fax and email to request medical records to validate encounter data and hierarchical condition categories (HCC) recapture scores for the Disease Burden Management (DBM) program. If you’re contacted by our Risk Adjustment team, please follow the instructions in the communication you receive and send all requested documentation via your preferred delivery method by Jan. 30, 2025.
Reminder: You Must Complete Our 15-Minute, 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.
Who needs to complete Model of Care training?
All providers who are part of the Priority Health Medicare Advantage network need to complete training. This includes specialists, ancillary providers, or anyone part of an ICT (interdisciplinary care team) for a D-SNP member. This is a CMS requirement.
Training needs to be completed and attested to by December 31, 2024. Late submissions will not be accepted.
Reminder: How to Correctly Submit Requested Medical Records for Claims Processing
Occasionally, we request medical records to accurately process a claim for payment. As a reminder, if you receive a request from us to submit medical records, the correct process is outlined below.
Following the above process will ensure your medical records are linked to the appropriate claim right away, whenever possible, and will support a timely resolution and claim payment.
Reminder: Informal Claim Reviews Are Required Before Appeals
It’s important to us that we accurately process your claims, and you understand the way your claims are handled.
To support you through the claim dispute process to make sure your questions / concerns are addressed in a timely manner – and you’re paid accurately and fairly for the care you’ve provided to our members – we’re sharing a few reminders and tips for our claim review and appeal process.
Reminder: CGM Authorization Timeframes by Plan Type
We’re sharing a quick reminder of our allowed continuous glucose monitor (CGM) authorization timeframes by plan type:
- Commercial: 12 months
- Medicaid: 12 months
- Medicare: 6 months
We’ve recently received a few 6-month CGM authorization requests for members with commercial and Medicaid plans. We want to make sure you’re aware that last October, we updated our requirements for commercial and Medicaid CGM authorization requests and no longer require a new authorization with proof of provider visit every 6 months. You may submit your CGM authorizations for these members for 12 months at a time.
We made this change to help ensure our members with diabetes get the care they need when they need it, with as few barriers as possible.
Per CMS LCD requirements, Medicare CGM requests may be submitted for 6 months.