05/07/2019

Important Oncology Related News

Priority Health Removing Prior Authorization Requirement for Drug Related Clinical Trials

Effective May 1, 2019, the prior authorization requirement for drug-related clinical trials for Priority Health commercial and Medicare Advantage members have been removed.  Instead, in-network providers will need to inform Priority Health that the member is participating in a clinical trial via Clear Coverage.
 
Note: This is not a covered benefit for Medicaid members.
 
Why are we making this change?
Removing the prior authorization requirement and implementing a simple notification process through Clear Coverage will streamline the process while ensuring patients are getting the care they need.  
 
What providers need to do?
Prior to enrolling a member in a drug related clinical trial, a provider will need to inform Priority Health that the member is participating in a clinical trial by completing a small set of required questions regarding the nature of the clinical trial in Clear Coverage. A training guide has been created for providers who need assistance submitting the proper information. 
 
When billing a claim to Priority Health, providers will now be able to bill the appropriate Q0 and Q1 modifier to indicate the service was part of a clinical trial. Providers must bill according to the Clinical Trial medical policy.   
 
Device and surgical clinical trials will continue to require a prior authorization through the current process. Likewise, any trials for out-of-network providers/facilities will continue to require pre-approval.  Clinical trials for Medicaid beneficiaries are not covered. 
 
For a 6 month time period, prior authorization requests that are faxed in for these trials will be returned with a request to submit through Clear Coverage.  After the 6 month period, faxed requests will not be processed.
 
How to use Clear Coverage
You must have a secure login to priorityhealth.com to access Clear Coverage. If you do not have a login, please request one at https://www.priorityhealth.com/provider/request-an-account.
 
If you already have a login, to access our Clear Coverage prior auth tool, login at priorityhealth.com  and “Request an Authorization.” For additional information on how to use Clear Coverage further, see the attached how to guide. 
 
Read the full Clinical Trials medical policy. 
 

Should you have any questions, please contact me directly. 
 
John Fox, MD, MHA | PriorityHealth
Vice President, Associate Chief Medical Officer
Cell: 616.460.0241
Office: 616.464.8454
Fax: 616.942.0024

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