02/19/2019

Priority Health

News Updates

Many thanks to MSHO Managed Care Committee Member Robin Frey for sharing these important updates with our members.

Robin Frey, CPC, CHONC
Reimbursement Manager 
Cancer & Hematology Centers of Western Michigan, PC

Modifier required for 340b payable drugs, recoupment upcoming for 2018 claims

Effective Jan. 1, 2018, Medicare began to reimburse payable drugs and biological agents purchased through the 340b program at an adjusted amount for those hospitals paid under the Hospital Outpatient Prospective Payment System (OPPS). The 340b program gives drug subsidies to pre-qualified providers through the Health Services and Resources Administration (HRSA) of the federal government. Because these drugs and biologicals are obtained at a subsidized rate, they must be billed with the JG and TB modifiers.

As of January 19, 2019, Priority Health will deny any claims billed by a 340b eligible facility for these payable drugs and biological agents billed without the proper modifiers. In addition, we will begin recouping payment for any claim paid in 2018 that was not billed with the proper modifier. Providers are encouraged to rebill any recouped claims with the proper modifiers.

Patients will not be directly impacted, other than potentially receiving additional EOBs as claims are recouped and reprocessed.

Reminder: No longer accepting fax submissions for record requests and appeals starting March 4

As of March 4, 2019, Priority Health will no longer accept fax submissions for record requests and appeals. This documentation should be submitted online through our provider portal. If you submit via fax the request will not be processed.

If you receive a claim denial that requests medical records, or you have a need to submit an appeal, submit through our provider portal by following these steps:

1. Log in to your Priority Health provider account.
2. Go to your Priority Health Secure Mailbox.
3. Select "compose a message."
4. For the "To" address, choose "Medical Record Submission" or "Appeals" from the drop-down list. Reference the original claim number or inquiry number (if available).
5. Attach the medical records or appeal form to your message.

If you're unsure of how to use your secure mailbox, see use your secure mailbox for additional information.

Provider website pages moving outside of login

Updated Jan. 17, 2019:  Starting in December, we began moving Provider Center pages from the logged-in Provider Center to the Provider Out-of-Network Guide, so you don't have to log in to see them. We renamed the Out-of-Network Guide the Provider Manual. The process of moving pages will continue throughout January.

Reminder: Effective Jan. 1, step therapy added for Medicare Part B drugs

Effective Jan. 1, 2019, Priority Health is adding step therapy requirements for a variety of Medicare Part B drugs (under the medical benefit) for new starts only. Specifically, we'll be adding step therapy to Part B drugs that currently have a prior authorization requirement in place.

What is step therapy
Step therapy requires a member to first try certain drugs to treat their medical condition before we'll cover another drug for that condition. For example, if Drug A and Drug B both treat a medical condition, we may not cover Drug B unless they try Drug A first. If Drug A does not work, we'll then cover Drug B.

All drugs with step therapy starting Jan. 1, 2019: Aveed, Benlysta, Botox, Cinqair, Fasenra, Inflectta, Krystexxa, Nucala, Remicade, Renflexis, Rituxan, Soliris, Xeomin.

This article is older but just came up again with the issues with the Medicare policy regarding 5-FU.  We were hoping PH would automatically reprocess these claims but we need to submit corrected claims instead.

System updates associated with CMS releases

When the Centers for Medicare and Medicaid Services (CMS) change or update their coverage policies or pricing, they allow health plans up to 30 days to reconfigure our systems in response. At times this will not align with the implementation of the changes for traditional Medicare or Medicaid.

New or revised National and Local Coverage Determinations (NCDs and LCDs)
We update our systems with NCD and LCD changes within 30 days of the release date from CMS or local MAC carrier.  Updates to NCDs/LCDs are not retrospectively applied to claims that have already processed in our system.

Pricing/payment updates
We implement pricing updates associated with changes to the Medicare and Medicaid payment systems within 30 days of release date from CMS.

Payment system updates are not retrospectively applied to claims that have already processed in our system.