02/16/2022

Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga, Cancer & Hematology Centers of West Michigan

The C-Code billing only applies to the specific brand of Auromedics Cyclophosphamide

The C-Code billing only applies to the specific brand of Auromedics Cyclophosphamide. As long as the facility is not administering that brand, the J-code of J9070 will still pay, is still covered, and no prior authorization is required - including facility billing.

New Provider Enrollment Requires 90 Calendar Days
When a new provider seeks to enroll in our networks, the enrollment process takes up to 90 calendar days from application to welcome letter, at which point they can start seeing our members.

Our Provider Manual previously listed this timeline for new provider enrollment as 62 calendar days, with a note that it didn’t include time for contracting. We know it’s important that you have a holistic understanding of our enrollment timeline, which is why we decided to make this update – adding contracting into our stated timeline. It’s not a change, but rather increased transparency between our teams and yours.

All new provider enrollment requests go through prism, our provider portal. There you can see your enrollment application’s progress and communicate with our teams as they process your application. Learn more 

Anatomic Modifiers Required Starting Apr. 1, 2022

Following the American Medical Association’s CPT coding guidelines, we’ll require appropriate anatomic modifier codes on claims starting Apr. 1, 2022. We’ll implement a new clinical edit, which will apply to all claims. If you’d like to see how this applies to a sample claim, try our online Edits Checker tool.

These modifiers supply more information that includes site or side of the body a procedure was performed and meets the highest level of specificity in coding.  READ MORE

Submitting Claims for Medicaid Members with Other Insurance

When two or more health plans cover the same member, we coordinate between plans following these steps:

1. Identify if other coverage exists
2. Review documentation to determine the correct order of benefits
3. Update our FACETS claim processing system with other benefits
4. Calculate the allowable expense
5. Process the payment

Read More, including what the State wants to see on your claims!