12/16/2024

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. 

New Resources Available for the HMA Product, Launching January 1
As previously announced, our new third-party administrator (TPA) product, HMA, is taking effect on January 1 for the employer groups and their members who have purchased it. To make sure you’re as prepared as possible, we’ve created an HMA page in our provider manual. This page includes:

• Sample member ID card images
• Guidance on working with members: eligibility, prior authorization, claims, appeals, support
• Information on the HMA provider portal
• A breakdown of HMA tools and when to use them
• Information for providers outside of Michigan
• FAQs
• Additional resources, including a short video

Visit the HMA landing page 

Final 2025 PIP Program Manual and Supporting Resources are Now Available
Our final 2025 PCP Incentive Program (PIP) manual and supporting resources are now available. Find information about each below and access the manuals / resources on our Provider Incentives webpage (login required).

Final 2025 PIP Manual
The following updates were made since the preliminary manual was released on Oct. 1:

• Program measure grid (pg. 6) 
  • The product payout and product targets have been finalized and are included in this final manual.
• Administrative details (pg. 7)
  • The PRA attestation information was updated to reflect the requirement to submit Group / Subgroup information for each PCP.
  • The Manual revisions information was updated to include information about a new Reports Data Dictionary, to be sent to ACNs with the first 2025 PIP reports in Mar. 2025. It will include the file requirements for our HL7 / APS data feeds to allow care gap closure.
  • The Quality Index measures were updated to include Statin Use for Patients with Diabetes (SUPD), Statin Use for Patients with CVD (SPC), Medication Adherence – Diabetes, Medication Adherence – Hypertension and Medication Adherence – Cholesterol.
  • The program deadlines were updated to be more comprehensive.
• Access to Care measure removed 
  • As announced in late October, the Access to Care measure has been removed from the 2025 PIP program.
• Disparity of Care measures (pg. 16) 
  • The product payout and targets have been finalized and are included in this final manual. Additionally, Disparity of Care will now be measured at the practice level.
• Care Management measure (pg. 20)
  • Removed G0511 as a code that will no longer serve to identify members that have received care management services. Added payout PMPM and updated prepayments to quarterly. Clarified use of codes 98966, 98967 and 98968.
• Health Information Exchange Participation with MiHIN (pg. 24) 
  • Update to note that SDoH use case participation is required to meet the measure.
• Appendix 1 (pg. 28) 
  • Removed the following codes from the list of procedure codes indicating a PCP visit on which attribution is made: 99201, 99245, 99384, 99403, G0402.
• Appendix 2 (pg. 29) 
  • Added information about the Report Data Dictionary.
• Appendices 4-7 (pg. 34-46) 
  • Added updated appendices

2025 Provider Roster App (PRA) Manual
Our PRA manual has been updated for 2025 to reflect the requirement to submit group / subgroup information for each PCP. The PRA attestation cycles information has also been updated.

2025 HEDIS Provider Reference Guide
Our Healthcare Effectiveness Data and Information Set (HEDIS) Provider Reference Guide has been updated to reflect 2025 new and retired HEDIS measures. These changes were determined by the National Committee for Quality Assurance (NCQA).

• HEDIS measures retiring in 2025:
  • Antidepressant Medication Management (AMM)
• HEDIS measures moving from hybrid to Electronic Clinical Data Systems (ECDS) measures only:
  • Childhood Immunization Status (CIS)
  • Immunizations for Adolescents (IMA)
  • Cervical Cancer Screening (CCS)
• HEDIS measures added in 2025:
  • Documented Assessment After Mammogram (DBM-E)
  • Follow-up After Abnormal Mammogram Assessment (FMA-E)
  • Blood Pressure Control for Patients with Hypertension (BPC-E)

Coming soon
Additionally, we’ll soon release the following:

• 2025 Disease Burden Management (DBM) program manual
• 2025 HEDIS ECDS Guide

Reminder: The Best Way for Practices to Communicate With us is Through Prism
The best way for practices to communicate with us about questions and requests is through prism accounts – not email.

By communicating through prism, we’re better able to:

• Route requests to the appropriate team for faster response or resolution
• Connect the inquiry to a specific claim, enrollment request, etc.
• Track the history of the correspondence 

Our Get Your Questions Answered document outlines how to submit questions through prism and route them to the appropriate Priority Health team. We encourage you to bookmark the URL for quick access to the most up-to-date version.

Visit our prism resources webpage for information on how to sign up for a prism account, a helpful video on when and how to reach out to us via prism, step-by-step instructions for common needs, and more. 

Reminder: Credentialing and Enrollment Status Updates are Available in Prism
If you need an update on the status of your credentialing or enrollment request, you can easily find it in prism.

There are two ways:

1. In prism, click Enrollments & Changes. You’ll find a list of enrollment / change requests with columns for date submitted, current stage of the process and status.
2. Under Enrollments & Changes, click on the Inquiry ID for the enrollment / change in question. There’s a status bar showing what part of the process you’re in (contracting, credentialing, enrollment, reimbursement or complete), as well as any comments. Don’t add a new comment requesting a status update. Our system automatically pushes inquiries with new comments to the bottom of the queue, and this will delay your request.

When your enrollment request is complete, you’ll receive a comment on your inquiry in prism, as well as a notification via email alerting you to the comment, that will include your effective date. Please remember:

• Our timeframe for processing new enrollments is 80 days.
• Each step in the enrollment process has a unique timeframe that falls within the 80 days. Credentialing is the most time consuming, so you may see your inquiries in this stage for most of the process. This is normal.

For more information, our credentialing webpage shows step-by-step instructions and more information on how to check the status of a request, timelines and more. If your request has exceeded 80 days, email exceedsprocessingtime@priorityhealth.com.