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Get our updated 2023 PIP Manual
We recently updated our 2023 PCP Incentive Program (PIP) manual (login required). Here’s a summary of the changes:

Care Management (pg. 18)

• Clarified that if a PCP retires or leaves the network, those touchpoints won’t count

Social Determinants of Health (pg. 20)

• Added new z-codes, and a new rev code
• Fixed CPT code typos

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PCMH designations are now in Find A Doctor
PCPs’ Patient Centered Medical Home (PCMH) designations are now available in our Find A Doc tool. This addition will help our members find quality, in-network care near them.

What is PCMH?
PCMH is a model of care that puts patients at the forefront of care. PCMHs build better relationships between patients and their clinical care teams, transforming the way primary care is organized and delivered.

Practices that earn this designation have made a commitment to care that is comprehensive, patient-centered, coordinated, accessible and quality.

Where can FAD users see PCMH designation?
The PCMH designation logo is visible on applicable PCP profiles, on the PCP’s primary address only. Alternative addresses won’t reflect the designation.

How can you update your practice groups' PCMH status?
PCMH designation is part of ACNs' monthly PRA attestation process. We’ll update Find A Doc annually using the November PRA attestation.

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Patient discharge moves to Member Inquiry as Patient Profile retires
In January 2024, our online patient discharge tool will move from Patient Profile into prism’s Member Inquiry tool. This change comes as Patient Profile is set to be removed from prism on February 1 as part of our Digital First data strategy.

Any patient discharges submitted through Patient Profile after the new tool’s launch won’t be processed.

In the coming weeks, we’ll share the exact implementation date and step-by-step instructions for submitting patient discharges.

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HCC coding shifting to the V28 model starting Jan. 1, 2024
The Centers for Medicare and Medicaid Services (CMS) is phasing in the V28 model for risk adjustment to replace the V24 model for risk adjustment beginning Jan. 1, 2024. The new model has significant changes to HCC coding and diagnosis mapping.

What’s changing?
Below are highlights of the new V28 model for risk adjustment:

• The number of HCC categories increased from 86 to 115, and categories were renumbered
• Changes were made to diabetes coding, a very commonly reported condition
• Some diagnoses were removed entirely

Why is this important?
Coding accuracy and specificity are essential to capturing a patient’s full burden of illness, ensuring care management programs are offered to the right members and closing gaps in care.

For those participating in an alternative payment model (APM), reimbursement rates have the potential to change due to weight changes for some hierarchal condition categories (HCCs).

Learn how to be successful with the new coding requirements
We’re here to help. Register below for our upcoming webinar, “Understanding HCC coding: an introduction to the new V28 model for risk adjustment” for a comparison of the V24 and V28 models for risk adjustment and an overview of key changes, how these new requirements will impact you and how you can be successful.

Register here:
Tuesday, December 5, 12 PM
Thursday, December 7, 3 PM

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Updates on Priority Health narrow networks for 2024, including the new Southeast Michigan Network
Priority Health is pleased to continue offering our narrow network plans in 2024 to our members who want to control health care costs without compromising quality. These narrow network plans are available in select regions for members who purchase their own health plan.

Please continue to refer patients to providers within their network. Use Find a Doctor to see which providers are in your patient's network. Request authorization for instances where services are not available within their network.

Which narrow network plans will be offered in 2024?
We’re offering four narrow network plans in 2024:

• Corewell Health West Michigan Network (known in 2023 as Spectrum Health Partners)
• Bronson Healthcare Partners
• Southeast Michigan Network (more information below)
• Trinity Health East Network (now available only in Washtenaw, Livingston and parts of Jackson County)

There will no longer be a narrow network product option for the Ascension health system.

What is the Southeast Michigan Network?
We’re excited to introduce our newest narrow network plan, available for members who live in Wayne, Oakland and Macomb County. This plan includes coverage for Corewell Health (formerly Beaumont Health) and Trinity Health providers and facilities in Southeast Michigan.

Where can I find more information about the Southeast Michigan Network?
Visit our Southeast Michigan Network informational landing page for more information, including tips on identifying patients who are part of this Priority Health plan and more detail about which facilities are included in this network.

What resources is Priority Health making available to ensure all impacted providers understand the Southeast Michigan Network and all other narrow network plan updates?
The following resources are available to any provider who needs more information:

• News item
• A printable one-pager
• Southeast Michigan Network informational landing page
• Virtual Office Advisory webinar, with an introduction to Priority Health’s 2024 narrow network product offerings
• 2024 Product Guide for Providers (will be sent separately at the beginning of November)
• The narrow networks page in the Provider Manual, which will be updated with 2024 information after Dec. 31, 2023

Thank you for continuing to support our members throughout Michigan. Please don’t hesitate to reach out with questions.

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2024 product guide for providers is now available

We’re excited to share several 2024 product updates for our commercial and Medicare members. Product updates were previously shared at our October VOA. If you missed it, we’ve created a 2024 product guide for you to learn about the new benefits available to your patients and any changes to existing benefits you’ll want to know about. 

We hope you find our new provider product guide helpful for your organization.  

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Introducing Carelon Health, a new name for Aspire Health
In an effort to provide extra care at home for our members with advanced illnesses, in 2016, we started working with Aspire Health to offer 24/7 in-home palliative care support from a team of doctors, nurse practitioners, social workers and clergy.

We wanted to let you know that Aspire will soon have a new name: Carelon Health.

Although the name will change on January 1, your patients will receive the same care. This won’t replace the care of primary and specialty providers. A member’s participation with Aspire (Carelon) doesn’t impact their PCP-attribution.

There’s nothing you or your patients need to do. Nothing will change regarding patient referrals or your work with Aspire’s clinical staff.

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Medicare annual wellness visits can be scheduled once per calendar year, starting Jan. 1
You asked, and we listened. Effective January 1, 2024, annual wellness visits (AWVs) for our Medicare members can now be scheduled once per calendar year, rather than the previous once per twelve months.

Why are we making this change?
We’ve been hearing requests for this change for a variety of reasons:

• The ease of tracking patients' visits on a calendar year basis rather than on a rolling 12-month basis
• Getting members in for appointments sooner, especially if they travel for part of the year
• Overall flexibility with practice scheduling

Bottom line: we want to accommodate you and our members, and this was a way for us to do both.

A couple examples of how this would work:

1. A member has an AWV on December 30, 2024. They will be covered for an AWV scheduled any time in 2025, from January on.
2. A member has an AWV on January 2, 2024. They would not be covered for another AWV any other time that year.

Thank you for providing excellent care for our Medicare members. As always, we appreciate your engagement and feedback.

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Meijer Specialty Pharmacy no longer a participating network specialty pharmacy for commercial and individual members beginning Jan. 1, 2024
Beginning Jan. 1, 2024, Meijer Specialty Pharmacy has chosen to no longer participate in our specialty pharmacy network for commercial and individual members. This change only impacts drugs covered under the pharmacy benefit. Drugs covered under the medical benefit aren’t affected.

Medicare and Medicaid members can continue to use Meijer Specialty and retail pharmacies for all their prescriptions. All members may continue to use Meijer’s retail pharmacies for their prescriptions that don’t require a fill at a network specialty pharmacy.

How will this impact members?
Members have always had the option to fill their specialty prescriptions through Accredo, and beginning Nov. 1, 2023, Corewell Health Specialty Pharmacy will be added as a newly participating network specialty pharmacy. Members won’t see any impact on their cost share when transferring to Accredo or Corewell Health Specialty Pharmacy.

How will members receive their medications?
Corewell Health Specialty Pharmacy can deliver to any address in Michigan and can fill all specialty medications except limited distribution drugs (LDD), which must still be filled by Accredo. Accredo can ship anywhere in the United States.

Will current prescriptions be transferred?
Only prescriptions with remaining refills will be transferred to Accredo or Corewell Health Specialty Pharmacy (as dictated by medication type, out-of-state delivery, etc.). To avoid interruptions in therapy, providers should consider sending a new prescription directly to Accredo or Corewell Health Specialty Pharmacy.

ePrescription information:
Corewell Health Specialty Pharmacy

• National council for Prescription Drugs Program (NCPDP) identifier: 2382531
• 41965 Ecorse Rd. Ste 100 Van Buren Twp, MI 48111

Accredo

• NCPDP: 4436920
• 1640 Century Center Parkway Memphis, TN 38134

How are we communicating this to members?
Impacted members will receive letters from both Priority Health and Meijer advising them of their drug coverage changes and what steps they can take prior to Jan. 1, 2024.

Members are being directed to reach out to their preferred in-network specialty pharmacy (Accredo or Corewell Health Specialty Pharmacy) and request the pharmacy contact their provider about submitting a new prescription.

Thank you for your continued commitment to the health and wellbeing of your patients, our members.

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