04/07/2020

Priority Health Update

Changes to CMS's National Correct Coding Initiative resulting in some claims reprocessing, starting Apr. 1, 2020

Update: A previous version of this article stated that we would not be reprocessing claims paid via the Ambulatory Payment Classification (APC) model. We've determined that some APC model claims will have a change in payment as a result of the retroactive changes made to CMS's National Correct Coding Initiative (NCCI) policies. Therefore, we'll be reprocessing APC model claims so those that require additional reimbursement will receive it. 

The Centers for Medicare and Medicaid Services (CMS) has made multiple retroactive changes to its National Correct Coding Initiative (NCCI) policies.

Our systems will be updated by Apr. 1, 2020 to reflect these changes. We'll reprocess impacted facility and professional claims with dates of services of Jan. 1, 2020 and after across all product lines, including Medicare, Medicaid and commercial group and individual.

What were the changes?

·         CMS temporarily deleted procedure-to-procedure edits for several radiopharmaceuticals retroactive to Jan. 1, 2020

·         HCPCS radiology codes G2061, G2062 and G2063 replaced G2029, G2030 and G0231, effective Jan. 1, 2020

·         CMS retained edits in effect prior to Jan. 1, 2020 for various code pairs related to physical therapy

What should you do?

There are no changes to how you bill, and you should not submit appeals for claims with these codes. We'll reprocess impacted claims according to CMS's changes starting Apr. 1, 2020. This may result in payment of previously denied services.

Healthy Michigan Plan work requirements canceled, effective immediately

Effective immediately, the new work requirements for Healthy Michigan Plan (HMP) members, which went into effect on Jan. 1 2020, have been canceled.

HMP members across the state no longer need to report their hours of work or qualifying activities every month to maintain coverage. This includes approximately 33,000 Priority Health members.

Background

On Jan. 1, 2020, the Michigan Department of Health and Human Services (MDHHS) implemented new work requirements for individuals with the Healthy Michigan Plan. On Mar. 4, 2020, a federal judge ruled that approval of HMP work requirements was unlawful.

What action do I need to take?

If you are utilizing HMP work requirements-related materials that were previously issued by MDHHS, you should remove these documents from circulation.

Visit the MDHHS website for more information about this change. If you have questions about the change, you can email HealthyMichiganPlan@michigan.gov. 

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Special thanks to our 

Priority Health Managed Care Committee Member

Flora Varga

from

Cancer, Hematology & Rheumatology Centers of West Michigan