05/06/2020

Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga, Cancer & Hematology Centers of West Michigan

We're removing prior authorization requirements for infliximab

Effective May 6, 2020, we’re removing prior authorization requirements for infliximab products for commercial group and individual plans.

Site of service restrictions still apply

Site of service restrictions for infliximab will still apply. For commercial group and individual products, we require patients to have infliximab injections in the home or office setting, or an alternative Priority Health-approved site of service.

For more information, reference medical policy 91414. 

Background

Infliximab products are a medical injectable typically used to treat a variety of autoimmune disorders.

We cover two infliximab products, Inflectra^TM and Renflexis^TM, which are biosimilars for the drug Remicade, and are the preferred drugs for our commercial (traditional and optimized) formularies.

Why are we making this change?

We’re lifting the requirement due to biosimilar competition driving down drug prices and to reduce administrative burden of prior authorizations.

Updated process for peer-to-peer reviews starts July 1

Starting July 1, you'll have one phone number to call if you want to schedule a peer-to-peer conversation with a medical director for inpatient and outpatient services to help you work with us quickly and easily. The phone number is 616.464.8432.

We've also expanded our hours of operations. You can contact us Monday—Friday, 8:30 a.m. - 4 p.m.  There's no change to the process for behavioral health services. Behavioral health providers should continue to call 616.464.8500.

What is a peer-to-peer review?
The purpose of peer-to-peer discussion is to exchange information regarding the medical necessity of a denied prior authorization request. The call does not take the place of documentation required to support authorization.

How do I request a peer-to-peer review?
You must schedule a peer-to-peer review within certain time frames, which vary depending on the authorization type.

Commercial formulary changes coming July 1, 2020

In July and January of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial formulary to ensure our members have access to safe, effective, and affordable drugs.

So far in 2020, we’ve added 45 new drugs to the formulary. We’ve also made positive changes (reduced tier or removal of authorization requirement) on 11 drugs, which helps make them more affordable to our members.

On July 1, 2020, we’ll have 28 drug changes that either remove a drug from the formulary or increase the tier the drug is in. These changes impact approximately 3,420 unique members.

How we’re communicating to our members
Members who are impacted by any changes to the formulary receive a letter advising them of how their drug coverage will be changing and what steps they can take prior to July 1, 2020. The letters also include a list of alternative medications that may be options for them.

Learn more
Our May 21 Virtual Office Advisory webinar will cover these changes. Join us to ask questions and learn more. 

Change Healthcare to begin Medicare chart reviews 

The Centers for Medicare and Medicaid Services (CMS) require all organizations participating in the Medicare Advantage (MA) program to submit complete and accurate diagnostic data to CMS for all beneficiaries enrolled in a MA plan. The diagnostic data submitted is used to predict the relative health risk status of individuals during the next calendar year and must be supported by valid documentation within the patient’s medical record.

Priority Health has partnered with Change Healthcare (formerly Altegra Health) to conduct the review of patient charts on our behalf.

We're sending letters to Medicare providers
The Medicare Risk Adjustment team is sending letters to our Medicare providers, informing them of the upcoming chart review. The letter is accompanied by a packet that includes the steps providers need to take to submit medical records to Change Healthcare. Per the letter, a Change Healthcare representative will follow up with each Priority Health Medicare provider in the coming weeks.

Contact information for Change Healthcare
Providers with questions about this process can contact Change Healthcare directly at 855.767.2650.

We’ve made changes to how we process and give updates on provider requests 

On March 6, 2020, we made changes our provider operations workflow, which impact how we internally process provider requests, including requests for network participation and change requests.

As a result of the new workflow, new providers who submit a request for participation may not treat Priority Health members until their request is complete and they are set up in our system. Upon completion of their request, providers will receive an email communication that includes a network effective date, which they can begin billing for dates of service on or after. Claims submitted before the effective date may result in incorrect payment or denial.

Participating providers who are requesting to make a change will receive an email communication from us that includes the effective date of change. Providers may begin billing for dates of service on or after that effective date. Claims submitted before the effective date may result in incorrect payment or denial.

As a reminder, you must notify us of changes in your address, staff, tax ID number at least 60 days prior to the change taking effect. We require 90 days advanced notice prior to retirement or termination of contract with Priority Health.

We’ve made improvements to how we’re keeping you informed of the status of your request
We know how important it is for you to stay informed on the status of your requests. We also recognize that every request is unique, and not all workflow steps may be required to complete your request. That’s why we’re launching a new communication process to keep you updated on the status of your unique request, every step of the way.

This new communication process will replace the “Now processing requests” timeline previously located on our website. Rather than providing you with this general processing time frame, we’re now able to send you information specific to your request.

How it works
After a request is submitted, you’ll receive an initial email from us, letting you know we’ve received your request. You’ll also get an inquiry number associated with the request. Keep the inquiry number in a safe place, because it will help us locate your request if you have questions.

Following this initial communication, you’ll receive updates from us at each step in the process, letting you know the status of your request, including any action items or additional information we need from you (if applicable).

Once your request is complete, you’ll receive a final communication from us that includes your effective date. You can begin billing for dates of service on the effective date. Claims submitted before the effective date may result in incorrect payment or denial.

Remember, if submitting a request for new provider participation, you should not treat Priority Health members until you are completely set up in our systems.

For more information
See the Requirements & Responsibilities section in the provider manual.

Supporting facilities with extra funding: DRG uplift and suspending Medicare Advantage sequestration 

To help our facility partners as they care for our Medicare members during this financially challenging time, we're making two temporary changes:

Providing a 20% DRG reimbursement uplift for hospitalized Medicare members with COVID-19
Hospitals will receive a weighting increase of 20% for members diagnosed with COVID-19 and discharged.

The uplift is applicable for claims with COVID-19 discharges between:

• January 27, 2020 to March 31, 2020 for B97.29
• January 1, 2020 to the end of the public health emergency—as determined by CMS—for U07.1

The 20% will be added on to the diagnosis-related groups (DRG) payments, without any budget neutrality adjustment.

We'll be holding these claims until we’re able to update our payment systems. We anticipate claims will begin paying around May 20.

Suspending Medicare Advantage sequestration
CMS started sequestration in 2013 as a 2% claims payment reduction to applicable services for Medicare Advantage. From May 1, 2020 to Dec. 31, 2020, we'll be suspending sequestration and passing along the 2% to providers for services impacted by sequestration.

Reprocessing claims
If claims have already processed, we'll reprocess to ensure appropriate payment.

Due to the accelerated timeframes in which CMS changes were made, we’ll audit claims in May that may be impacted by these scenario to ensure appropriate payment.

Priority Health reserves the right to modify these policies should circumstances warrant.

Biosimilars preferred over Herceptin, Avastin and Rituxan, effective July 1

Beginning July 1, 2020, we’ll be preferring lower cost biosimilar products over Herceptin^® (trastuzumab), Avastin^® (bevacizumab) and Rituxan^® (rituximab) when used for the treatment of cancer(s) for patients who are new to therapy. This change impacts all product lines, including commercial group, individual, Medicaid and Medicare.

Why we’re making this change
Our Pharmacy and Therapeutics Committee (comprised of network physicians) monitors the availability of new biosimilars, which have been proven to have no meaningful difference in safety, purity or effectiveness for our members and can help them save on out-of-pocket costs.

Preferred biosimilar products and billable codes
A list of preferred biosimilars and billable codes is included below.

Prior authorizations
Herceptin and Avastin do not currently require prior authorization. Therefore, their preferred biosimilars will not require prior authorization. Although Rituxan currently has a prior authorization requirement, we are removing the prior authorization for Rituxan biosimilars for individual, commercial group and Medicaid. At this time, we’re not removing prior authorization for Rituxan or Rituxan biosimilars for Medicare.

For patients currently on Herceptin, Avastin or Rituxan
This change will impact new starts only. Members currently receiving treatment using a non-preferred product will be able to continue their treatment.

Members receiving Avastin for the treatment of ocular disorders will not be required to use preferred biosimilars. Providers should be using a different code to indicate its use for treating ocular disorders. If a provider incorrectly bills for treatment of ocular disorders using the cancer code (J9035), the code will be denied.