Priority Health Update
Priority Health Managed Care Committee Member
Flora Varga, Cancer & Hematology Centers of West Michigan
New clinical edit goes into effect Oct. 15, 2022
Ensuring your patients, our members, receive the right care at the right price is central to our partnership with you and all providers in our network. To help us achieve this goal, we’ll implement a new clinical edit – “Diagnosis Coding, Excludes1” – on October 15.
Coding to the highest level of specificity
This edit stems from ICD-10 coding guidelines, which require coding to the highest level of specificity. Their Excludes1 criteria details diagnosis codes that shouldn’t be reported together because the two codes can’t occur at the same time.
Resubmitting denied claims
You’ll be able to resubmit denied claims with corrected diagnosis codes to receive payment.
Get more information
Reference the ICD-10 coding manual’s Excludes Notes section for more detail and examples.
PriorityWell Choice Benefits launching Dec. 1, 2022 for commercial large groups; HealthbyChoice retiring by 2024
PriorityWell Choice Benefits (PWCB) will be available for fully and self-funded large groups beginning Dec. 1, 2022, with small group availability beginning in 2024. The new product was developed to encourage year-round engagement for members, with an elevated member experience from HealthbyChoice. Groups who are currently enrolled in HbC will start transitioning to PWCB based on their renewal date. HbC will sunset from the product portfolio over the next two years.
What’s changing for providers
There’ll be a new biometric screening form for this product that providers will be asked to fill out for their patients who are enrolled in PWCB. Providers can expect to see this form beginning Dec. 1, 2022 and beyond. Unlike the current HealthbyChice form, providers won’t be required to submit this new PWCB form to Priority Health. The member will be responsible for submitting the form through their Virgin Pulse account.
This new wellness plan doesn’t reimburse providers for form submissions since members are responsible to submit the form. However, while members are still transitioning from HbC to PWCB, providers will continue to be reimbursed $30 for any HbC forms that are submitted to Priority Health through the HealthbyChoice portal until the product has completely retired in 2024.
What else providers need to know
The HealthbyChoice form can’t be used as a substitute for the new PriorityWell Choice Benefits form
- An example of the new form can be provided to provider offices upon request. Please don’t duplicate/circulate to members, as the information on the form is distinct to their employer and as an individual
Reminder: Cigna members traveling through Michigan are covered in our PPO network
Cigna members who are under different health plans are covered by Priority Heath through our Strategic Alliance with Cigna. This means that Cigna members traveling in Michigan who have health plans covered under a Cigna Strategic Alliance can see our in-network PPO providers.
Several providers have been balance-billing these members who have an alliance with Cigna but should only be billing patient liability as shown on the Cigna or Strategic Alliance remittance advice.
What providers need to do
You may receive remittance advices from other Cigna Strategic Alliances (see below). The remittance will indicate the Priority Health rate was applied using the Priority Health network. Providers need to honor the contractual obligations on the remittance and not balance-bill members for services under these alliances.
Cigna Strategic Alliances
- TUFTS Health Plan/CareLink (Massachusetts/Rhode Island area)
- HealthPartners (Minnesota, North Dakota, Western Wisconsin)
- MVP (Upstate and western New York area, Bradford county, PA)
- Priority Health (Michigan's Lower Peninsula) - effective January 1, 2021
Learn more about our partnership with Cigna
What this means for our provider partners
What to do when you see a Cigna member in Michigan
Cigna Strategic Alliance provider FAQ
Legacy THC providers must wrap up claims, appeals by Dec. 31, 2022
As our merger with Total Health Care (THC) is complete, THC will officially cease operations on Dec. 31, 2022. Legacy THC providers must wrap up any outstanding claims and appeals as outlined below.
What does this mean? READ ARTICLE
Visit the Priority Health Provider News Page for Additional Updates: CLICK HERE
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