07/23/2025
Priority Health Update
Priority Health Managed Care Committee Member
Flora Werle - The Cancer & Hematology Centers
Click here to visit the Priority Health Provider News Page for additional updates.
IMRT to be Added to Post-Pay Audit Program Effective Aug. 23
Effective Aug. 23, 2025, intensity modulated radiation therapy (IMRT) will be added to the scope of our Post Payment Complex/Clinical Audit (PPCCA) program, supported by our vendor, Performant Recovery, Inc. (Performant).
The PPCCA program already includes several outpatient and professional services and impacts all plan types.
July 2025 Billing Policy Updates
We publish billing policies to offer transparency and help you bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
The following billing policies were recently published to or updated in our Provider Manual’s Billing Policies page.
Warning: Fax Phishing Scam Claiming to be From CMS Asking for Patient Data
The Centers for Medicare & Medicaid Services (CMS) is warning of a phishing scam in which providers are being sent faxes requesting all Medicare patient information and records. The faxes generally demand this information in 72 hours.
Many of these faxes are using CMS headers for authenticity, or headers of other organizations, such as the National Archives and Records Administration (NARA).
Be aware of this ongoing scam and do not respond or share your patients’ information.
Reminder: Log Into Your Prism Account at Least Every 120 Days to Maintain Access
Make sure you’re logging into prism frequently. After 120 days without a login, your account will be considered inactive, and you’ll temporarily lose access.
What do I do if my account goes inactive?
If your account is inactive because you haven’t logged in for 120 or more days, you’ll need to call our tech support team at 800.942.4765, option 5, then 1.
If you’re a prism Security Administrator (pSA) and your account goes inactive, you’ll lose your pSA designation and will need to request pSA status again in prism under General Requests, then prism Security Admin (pSA) Assignment.
Why am I required to log in at least every 120 days?
We want to ensure that all prism users are current to maintain the security of your patient and practice data. Most prism users who haven’t logged on in more than 120 days no longer need access to that data.
Updates to Arine MTM Faxes
Arine, our Medication Therapy Management (MTM) vendor is updating how patient information is organized in MTM faxes to enhance readability and improve sustainability. Beginning mid-summer, you’ll receive MTM faxes with patient information grouped by the potential medication-related concern identified, rather than receiving separate faxes for individual patients.
Medicaid Audit Underway
The Centers for Medicare and Medicaid Services, in partnership with Unified Programs Integrity Contractors (UPIC) and CoventBridge, is conducting a Medicaid audit to confirm accurate payments were made for items and/or services provided under a state plan and to ensure no waste, fraud or abuse has occurred. The audit period for this review is Oct. 1, 2022, through Sept. 30, 2024.
What do you need to do?
CoventBridge may reach out to you with a request for medical records for some of your Priority Health Medicaid patients. If you’re contacted, please submit the requested documentation by their provided deadline.
Find more information on the UPIC audit here.
New In-Home Health Assessment Vendor
We’re partnering with Porter Cares Inc. (Porter) to provide free in-home and telehealth assessments for select commercial ACA, Medicare and Medicaid members who are at a higher risk for health complications or those who score higher on the Social Determinants of Health SDoH index and need additional support. Through Porter’s services, we aim to help close care gaps and improve health outcomes for hard-to-reach patients with chronic conditions and/or barriers to care.
Get the Information You Need to Use Prism Quickly and Efficiently
Have you had a question lately about how to use prism but found yourself unsure where to look? We’ve consolidated all prism resources here in one place.
TurningPoint Post-Claim Appeal Updates: Determination Letters & Exception for Cardiac Cases
We’re sharing a couple of updates on post-claim appeals for medical necessity for cases managed by TurningPoint.
Exception to the new post-claim appeal limitations for cardiac cases
Effective June 2, we no longer accept appeals for medical necessity review after a claim has been submitted when there’s a denied authorization on file for the following case types:
- Outpatient, home health, DME
- Elective inpatient
- Behavioral health
We ask that, in these cases, providers with a denied authorization submit their medical necessity appeal before performing the service.
Exception: We will still accept post-claim appeals for medical necessity review for cardiac cases managed by TurningPoint.
Billing Policy Reminders
We’re sharing a reminder about the following billing policies and requirements as we’ll soon implement clinical edits in alignment with the outlined information:
- Critical access hospital (CAH) method II billing
- Fundus photography
- Medicare preventive services/codes
- Radiation oncology
- Reimbursement for Diabetes Prevention Program participation
- Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
- Telehealth and virtual services
The denial codes and descriptions you may see on claims in prism have been added to each policy / page (except for Medicare preventive services/codes – the denial information will be added to this page soon).
Updated 2025 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 that we cover CPT 99484 (General behavioral health integration) for commercial and Medicaid in addition to Medicare.
Access the manual through our Provider Incentives webpage (login required).
Technical Denials no Longer Apply to In-Network Providers' Claims
We’re no longer applying technical denials to in-network provider claims.
A technical denial is an administrative claim denial issued when a provider doesn’t respond to requests for medical records. We began applying them to in-network provider claims in late Dec. 2024 and, due to low volume, determined in May 2025 that they were no longer needed.
If any of your providers received a technical denial, they may still submit the requested medical records to the vendor within 30 days of the denial for consideration.
Provider Experience Survey Being Sent to Providers and Provider Staff in Early July
Beginning the week of July 7, we’re sending out our Provider Experience Survey to providers who work with us, and we’re encouraging everyone who receives a survey invite to participate. Please be on the lookout for an email, phone call and/or letter from Press Gainey on behalf of Priority Health.
What is the Provider Experience Survey?
The Provider Experience Survey is an extensive provider satisfaction survey that allows you to evaluate the experience of being in our network. It’s administered by a third party, Press Gainey, who works with other major health plans to administer the same survey.
What do you need to do?
Be on the lookout for an email the week of July 7 from PriorityHealthProviderSurvey@sphsurvey.com. The survey is a random sample, so you may or may not receive an invite. It will go to both providers and provider staff.
To ensure the survey invite doesn’t go to your spam folder, check with your administrators or IT team to get that email address on your organization’s approved sender list. You may also be invited to the survey via phone or mail, so be aware that these calls and/or letters are legitimate and sent by Press Gainey on behalf of Priority Health.
Is there a response deadline?
Yes, you’ll have until August 20 to complete the Provider Experience Survey, but we encourage you to complete it as soon as possible upon receiving the invitation.
June 2025 Billing Policy Updates
We publish billing policies to offer transparency and help you bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.