08/18/2025
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.
Register Now for Our August 21 Medicare & Medicaid Quality Webinar
Join us for our summer quality webinar on Thursday, August 21 to learn about:
- Preventive care for Priority Health Medicare and Medicaid members
- Raising awareness for Falls Prevention Awareness Week
- SOGIE (Sexual Orientation, Gender Identity & Expression) data collection
How to register
You can join us by registering online.
Can’t join us?
All webinars are recorded and posted to our provider webinars page within a week of the event, so you can watch at your convenience.
August 2025 Medical Policy Updates
Our Medical Affairs Committee (MAC), comprised of Priority Health network physicians, met in August and approved the following medical policy updates. Unless otherwise noted, the changes will go into effect on Sept. 1, 2025.
Updates that may be relevant to MSHO members include:
- Breast Related Procedures *#91545)
- Home Care (#91023)
- Hospice Care (#91520)
- Infertility Diagnosis and Treatment / Assisted Reproduction (#91163)
- Medical Necessity Determination (#91447)
- Non-acute Inpatient Services (#91332)
- Prophylactic Cancer Risk Reduction Surgery (#91508)
- Sexual Dysfunction and Impotence (#91160)
August 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.
Updates that may be relevant to MSHO members include:
- Ambulance services
- Care management
- Colorectal cancer screening
- Drugs administered by providers for FDA-approved or medically accepted off-label uses
- Evaluation and management
- Frequency of care coordination services and ESRD procedures
- Frequency of hemodialysis
- Genetic testing, counseling and screening
- High tech radiology services
- Home health
- Infusion services supplies
- JA / JB modifiers
- Lab and pathology
- Smoking cessation
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.
What do you need to do?
We ask that you respond to medical record requests from Performant in a timely manner.
What's included in Performant's review?
IMRT coding reviews align with our Radiation oncology billing policy and focus on the evaluation of coding and documentation of medical procedures and diagnoses, including:
- Review of facility and professional claims
- Review of medical records and corresponding codes to verify accuracy
- Validation that documentation supports the codes assigned
- Identification of medical coding errors or discrepancies that result in incorrect payments
Note: coding reviews don’t evaluate medical necessity.
These reviews are based on national coding conventions as defined by:
- American Society for Radiation Oncology (ASTRO)
- American Medical Association (AMA) Current Procedural Terminology (CPT)
- Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual
Get Our Summer Physician and Practice News Digest and Our Medicare/Medicaid Quality Newsletter
Our summer 2025 Physician and practice news digest and Medicare/Medicaid Quality newsletter are here.
We send these newsletters to our ACN contacts and all providers with a prism account who have opted in to receive our communications. They include our latest news and updates and share information and ideas to help our providers work with us and provide the best care for our members.
Did you miss last quarter’s newsletters?
You can find our previous newsletters in our provider news archive.
Annova: New Vendor Supporting Medical Record Retrieval
We’ve partnered with Annova Solutions to support medical record retrieval efforts for Priority Health-led and state-required audits.
Why it’s important
Timely and efficient record retrieval can improve quality performance and helps ensure we’re adhering to state and federal regulations.
How will Annova contact providers?
Annova will reach out to providers primarily through phone and fax. All outreach will be sent on Priority Health letterhead and/or will include a verifiable Priority Health phone number or email address. Get more information on how to spot phishing scams and fraudulent record requests.
Our vendor partnerships for record retrieval
We have active partnerships with the following vendors for medical record retrieval:
- Annova
- Datavant
- Datalink
- Veradigm
Note: The above vendors are limited to record retrieval conducted by our Risk Adjustment and HEDIS teams. Our Payment Integrity team contracts with the following vendors for provider outreach for post-pay audits: Machinify (fka, VARIS, LLC), EXLService and Performant Recovery, Inc..
Submitting documentation digitally
To maximize time and efficiency, we encourage you to prioritize digital submission methods when sending us medical records, if you’re able. These methods include:
- Remote EMR access
- A secure SharePoint folder (email ra@priorityhealth.com for setup information)
- Secure email
If you’re contacted for a records request, a full list of submission methods will be included in the communication you receive.
Medicare PA Criteria Updates Take Effect Oct. 1 for Non-Preferred Hyaluronic Acid Products
Effective October 1, prior authorization (PA) criteria will be updated for all non-preferred hyaluronic acid products for Medicare members to ensure they’re used in accordance with guidelines from the Centers for Medicare & Medicaid Services (CMS). Find updated PA requirements on the Medicare Local Coverage Determination (LCD) webpage (Jurisdiction 8) or by using the Medicare Coverage Database.
The following preferred hyaluronic acid products will remain covered with no PA requirements:
- Euflexxa
- Durolane
- Gelsyn-3
- Supartz FX
What do you need to do?
We recommend reviewing PA criteria before submitting a prescription for a non-preferred hyaluronic acid product or prescribing a preferred hyaluronic acid product.
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.