Medicaid patients

Priority Health has been selected as a Qualified Health Plan for West Michigan. Medicaid pays for medical assistance for individuals and families with low income and resources.

Jump to:

Annual open enrollment period Authorizations Benefits (goes to a new page)

Billing for services Eligibility Reasons to participate (goes to a new page)

Reimbursement Specialty network access Transportation

Annual open enrollment period

The annual open enrollment period in the State of Michigan is the month of May.

• Members who enroll/change plans before May 15 are effective June 1.
• Members who enroll/change plans after May 15 are effective July 1.

Authorizations

To see what services require prior auth, go to the authorization reference list in this manual.

Billing for services for Medicaid patients

You must use the subscriber ID (including the two-digit suffix), NOT the Social Security number, to identify the patient on both electronic and paper claims. Claims submitted without a valid subscriber ID or Medicaid ID number will be rejected.

• Go to the "How to bill" section of this manual.

Eligibility

Medicaid eligibility is determined at the local Department of Human Services (DHS) office. The DHS worker reviews the beneficiary's financial and non-financial information (e.g., disability, age, etc.) and determines type of assistance for which beneficiary is eligible. Once eligibility is established, data from DHS is available via the CHAMPS Eligibility Inquiry, and a mihealth card is issued for new beneficiaries.

Coverage usually is effective the first day of the month in which the beneficiary becomes eligible. Exceptions:

• Coverage may begin the actual day the beneficiary becomes eligible
• Beneficiary may be retroactive up to 3 months prior to the month of application if all eligibility requirements for the specific health care program were met and medical services were rendered.

If the individual does not voluntarily choose a managed Medicaid plan within 30 days, he/she will automatically be assigned by the State to a managed Medicaid plan available in the person's county of residence.

New Medicaid managed enrollees have 90 days from the date of enrollment to the initial managed Medicaid plan to switch to another plan. Barring this, they are considered "locked-in" until the next open enrollment period.

To access real-time eligibility log in at: http://healthplanbenefits.mihealth.org/ 

To apply for access to real time eligibility, go to: http://healthplanbenefits.mihealth.org/modules/application/terms.aspx
 Or, call MI Enrolls at 888 367-6557.

Newborns

• Newborns may be eligible for Medicaid enrollment for the month of their birth.
• The mother is required to notify the local DHS office of the birth of the newborn within 10 days of the birth.
• Newborns are not automatically enrolled onto the mother's plan. The mother must select a plan through Michigan Enrolls. 
• If the mother does not choose a plan, the newborn will be assigned to a plan listed in their county.
• The plan is responsible for all covered services for newborn unless the child is placed in foster care or enrolled in CSHCS.

Reimbursement

We pay Medicaid fees. Go to the Medicaid fee information at the michigan.gov website.

Specialty network access

Michigan Medicaid has developed a process and funding for referring patients in need of specialty care access to providers at "public entities" MSU, Wayne State, Hurley Hospital and the University of Michigan.

Our Medical Authorization Department has fully implemented the SNAF process. All staff members have been trained in how the process works for the use of the Public Entities for Specialty Care. The process is:

1. All providers referring for specialty care must first exhaust all efforts to find an in-network provider for the member's care.
2. If no care is available in-network, or the timeline to receive care is too long and the member's need is critical, and if the in-network provider cannot accommodate the member's need, we allow them to use the SNAF process and contact the public entity. 
3. The PCP completes our standard out-of-network referral form and sends it to Priority Health.
• Medical prior authorization form (256KB PDF)
4. Our Health Management team determines where the referral will go and provides an authorization number to the PCP. MSU subspecialists are generally the first choice due to their central location and business agreement with Priority Health. MSU specialists are listed on the access form.
5. The PCP completes the access form and forwards it to the appropriate public entity.
• MSU specialty care access form (32KB PDF)
• U of M specialty care access form

Transportation

Call and ask for transportation: 888 975-8102 or in Grand Rapids, 616 975-8102.