Incentive Programs
If you have questions about articles in this section, please contact your provider account
representative directly. (Physician account executives (PAE) are now provider account
representatives. See article in the News/Updates section.)
February 28 deadline for 2009 PIP dataRemember that to be included in Partners in Performance (PIP) 2009, all claims must be processed and data entry completed by February 28, 2010.PIP 2010 manualWe have combined the PIP brochure and technical manual into one document for 2010. We mailed the 2010 PIP manual to all PCP practices in December. You may also access complete 2010 PIP information through our Provider Center. To view PIP information online, you will need to log in.Change to non-adherent member exclusion requestsTo exclude a member in 2010, at least two of your attempts to contact the member must be in 2010.News & UpdatesNew titles, same facesOur Provider Network Services department has been reorganized for 2010. Previously, we had been operating with different department structures in our regions. Effective January 1, 2010, all regions began operating with the same organizational structure, job functions and job titles.
If you are unsure who your personal contacts are, contact us through the Provider Helpline at 800 942-4765. We’d be happy to put you in contact with them. Simplified ID cards issuedWe’re simplifying and streamlining member ID cards for many Priority Health commercial members. As new members join Priority Health, or change their plan, they’ll receive ID cards with the streamlined design. Existing members who aren't changing plans won’t receive new cards; their current cards will still be valid.The new member ID cards will no longer list copays, deductibles or ancillary coverage, and the prescription coverage indicator will be on the back of the card. To check patients’ benefits, please use Member Inquiry (available online in our Provider Center). Remember to verify plan informationPatients often make changes to their health insurance coverage on or after January 1. Some may have simply changed plans within the same company (switched from an HMO in 2009 to an HSA in 2010), or they may have switched to a completely new health insurance company. We can pay claims promptly and accurately when we have the correct information.UAW retirees with Priority Health will have new group and contract numbers in 2010 More than 6,000 United Auto Workers (UAW) retirees who use Priority Health have new group and contract numbers effective January 1, 2010. Please be sure to include their updated group and contract numbers on claims for services on or after January 1, 2010. There is no change to these members’ benefits. The change is a result of Ford and Chrysler changing their administrative processes. Spine COE updatePriority Health Spine Centers of Excellence (COE) program launched in the West and North regions November 2007. The initiative became state-wide with the launch of the program in East Michigan in May 2009. We wanted to remind you of the objectives of this program and share some successes.
2010 HEDIS® reviewsAnnually, Priority Health participates in HEDIS® (Healthcare Effectiveness Data and Information Set) methodology of collecting, measuring and reporting performance indicators. By doing so, Priority Health has the opportunity to measure the quality of care our members receive. In addition, we’re able to compare ourselves with other exceptional plans throughout the country, share this information with the public, and identify areas for improvement within the plan.HEDIS is the most widely used set of performance measures in the managed care industry and is developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS is part of an integrated system to establish accountability in managed care and contains 70 measures across eight domains of care. By contract, all of our providers have agreed to participate in Quality Assurance (QA) reviews; HEDIS is considered one of those QA reviews. Again, per contract, we have agreed to provide you with 30 days advanced notice of these reviews. This communication serves as that notice. Priority Health HEDIS reviewers will visit provider offices during March, April and May to collect medical record data. Under HIPAA, HEDIS is an approved activity, as it’s part of normal health care operations. We may conduct some reviews via fax to minimize interruptions to offices. If you would prefer to have a reviewer visit your office instead, let us know. Please welcome these reviewers into your office and assist them if they have questions. If you have questions about the process or reviewers, please contact Marcia Bartlett at 231 932-7964. Terminating employee Web accessPlease contact the Provider Helpline or your PAC immediately when you need to terminate access for an employee in your office. We’ll deactivate their access to member data and your provider accounts.Medical policy changesRemember to view the Recent Changes section on the left side of the online Provider Manual page for updates to medical policies and billing information.Vision benefits for small groupsEffective January 1, 2010, small employer groups (2-50 employees) now have a vision benefit embedded in their medical plan. This benefit covers one routine vision exam (including refraction) every 12 consecutive months with a $15 copay. Services must be obtained at participating provider offices.Note that this does not apply to HSA plans. Provider Helpline wait timeWe are aware of the high call volume and longer wait times being experienced through the Provider Helpline. We have recently added additional staff and expect wait times to go down in the weeks ahead. Thank you for your continued patience.Remember that many questions can be answered online through the tools available in the Provider Center.
Clinical SupportTelemonitoring available for high-risk heart failure patientsPriority Health is now offering telemonitoring services to heart failure (HF) patients who are at high risk of admission or readmission for exacerbations of their condition. Telemonitoring uses home monitoring equipment to measure a patient’s weight, blood pressure and pulse, and transmits clinical data to a registered nurse in a central location. Changes in clinical data prompt a call to the patient, and education or assessment is provided as needed. The patient’s physician is notified of a significant change in the member’s clinical status and can receive trended data to monitor the patient’s progress over time. Patients who are eligible for this service include those who have a history of HF and have:
URI and pharyngitis codingPlease make sure that these diagnoses are being billed correctly. We’ve recently identified cases where diagnoses are being billed incorrectly.Measure: Upper Respiratory Infection (URI) Description: The percent of children three months to 18 years of age who were:
Codes to identify visit type:
Codes to identify competing diagnoses:
Measure: Appropriate testing for children with pharyngitis (CWP) Description: The percent of children two to 18 years of age who were:
Codes to identify visit type:
Codes to identify Group A Streptococcus test:
* Do not include ED visits that result in an inpatient admission.
H1N1 virus, asthma and your patient’s asthma action planWith the swine flu making headlines, it’s important for asthma patients to have a personal Asthma Action Plan. Since both swine flu and asthma attack the airways, it makes people with asthma more vulnerable to pneumonia and asthma exacerbations. Have a clearly written plan on what actions your patients should take if they have the flu, such as monitoring peak flow rates, and having an inhaler and nebulizer on hand. Download an asthma action plan at priorityhealth.com/provider/clinical/asthma.Screen adolescents for depressionAlthough the USPSTF recommends adolescents ages 12 to18 receive an annual depression screening from their PCP, less than one-third of PCPs routinely screen their teen patients. Studies show 8.5% of teens, ages 12 to 17 during 2004-2006, suffered an episode of major depression and were twice as likely to increase their risk factors by using alcohol or drugs. Teens also suffer from social and separation anxiety, which often goes undetected in routine adolescent health visits. For a sample depression scale to screen adolescents visit priorityhealth. com/provider/clinical/depression.Are you testing for STIs?According to the CDC’s latest studies:
Testing for lead poisoningEvery child is at risk. Bans on leaded paint and gas have reduced the incidence of dangerous lead levels in kids, but many are still at high risk due to contaminated dust from remodeled homes, glazed pottery, stained glass and hundreds of toys and children’s jewelry products sold in many local stores.The costs of inaction are great. As children’s blood levels increase, so do the medical costs. High levels also cause irreversible learning disabilities, ADHD and more. Research shows a relationship between high lead levels and low IQs, which increases the need for special education services, reduces the likelihood of high school graduation and lowers lifetime earnings. It’s the law for Medicaid. All children in Medicaid must be tested—no exceptions or waivers exist. For a copy of the MDCH Statewide Lead Testing/Screening Plan and a list of high-risk ZIP codes, please visit michigan.gov. Additional resources are available at priorityhealth.com/clinical resources. Childhood Lead Poisoning: Conservative Estimates of the Social and Economic Benefits of Lead Hazard Control, Environmental Health Perspectives, July 2009. Free seasonal flu and pneumonia pocket guidesPriority Health has 1,000 laminated pocket guides for flu and pneumonia. These are produced by the National Influenza Vaccine Summit to assist healthcare professionals in vaccinating patients. The guides provide front-line information on indications and contraindications for the vaccines, details on how to administer the vaccines, information on target populations and more. If you would like a few pocket cards for your practice, please contact your PAR.Operational InformationCMS coding and documentation guidelines: Smoking and tobacco use cessation counseling servicesCenters for Medicare and Medicaid Services (CMS) has defined two CPT codes for documenting and billing tobacco use cessation counseling services.CPT codes to identify tobacco use counseling: 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than three minutes up to 10 minutes. 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes. Use codes 99406 and 99407 appropriately A cessation counseling session refers to face-to-face patient contact. Remember, a counseling session of three minutes or less is included in the evaluation and management (E&M) payment and is not separately reported or payable. Billing of E&M service with tobacco counseling When clinically necessary, E&M services are allowed on the same day as smoking and tobacco use cessation counseling. In order for E&M services to be billed with a tobacco counseling code, the services must be separate and identifiable or distinct. A 25 modifier is appended to the appropriate E&M code. Diagnosis codes identified with tobacco counseling CPTs Diagnosis codes need to reflect the patient’s condition that is adversely affected by tobacco use. Conditions that may be affected include diabetes, pregnancy or COPD. Documentation requirements for use of tobacco counseling CPTs Counseling time and details must be documented. Examples of documentation details include risks, programs/methods for quitting, impact on health and medication and interventions. In addition, documentation should identify sufficient patient history to adequately demonstrate coverage conditions were met. Correcting electronic 1500 claimsEnter Claim Frequency Type Code (billing code) 7 (for a replacement/correction) or 8 (to void a prior claim) in the 2300 loop in the CLM*05 03. If you don't know where the 2300 loop or 2300 NTE ADD fields are in the form you use, contact your software vendor. If your software vendor has additional questions, direct them to call the Priority Health EDI Helpline at 800 942-0954, ext. 48686. You also may find information in the online Provider Manual or contact the Provider Helpline or your PAC with questions.Billing preventive services with problem-oriented E&M servicesG0101 (pelvic and breast exam) and Q0091 (obtaining and preparing a Pap test for the lab) shouldn’t be reported with an E&M service (99201-99215) if the E&M service better describes the service rendered. Priority Health does not reimburse separately for G0101 or Q0091 when they are performed for indicated purposes on the same date as a problem-oriented E&M service. Breast and pelvic exams, including obtaining, preparing and conveying a Pap smear, are considered components of an exam and medical decision-making.If these codes are reported solely for the purpose of an unrelated screening service, Q0091 and G0101 may be separately reimbursed in addition to the problem oriented E&M service.
CMS confirms code eliminations and payment reductionsAs proposed in July, CMS has announced that they’re eliminating the use of all consultation codes effective January 1, 2010.How Priority Health is handling this:
How Priority Health is handling this:
Submit COB claims electronicallyThanks to provider awareness of the benefits of abandoning paper and adopting electronic claims, Priority Health now receives more than 90% of submitted claims electronically. The largest source of paper claims are those that contain COB information. We do not require you to submit COB claims on paper; in fact, we prefer electronic submission. To submit your electronic claims, include the other payer’s identification, dollar amounts and adjustment reason codes. This information is simply copied from the other paper’s electronic remittance advice (835). If you received a paper remittance, you may need to convert any non-HIPAA reason codes to the standard HIPAA codes. Work with your practice management system vendor to initiate the process.Demographic changesRemember to contact us when you have demographic changes to your practice. If our system is not updated with current provider information, claims payment may be delayed. You’ll find the Provider Demographic Change Form on our website.Data issues when using WellcentiveWhen you notice Wellcentive data issues please first contact Wellcentive to make sure the data was present and transmitted. If necessary, Wellcentive will work with Priority Health to resolve the issue.Patient-Centered Medical HomePriority Health supports the NCQA PPC-PCMH recognitionPriority Health is pleased to continue to support advancements in primary care into 2010 and will reward practices that have been recognized by the National Committee for Quality Assurance (NCQA), paying $1, $2 or $3 pmpm for 12 months (fully funded commercial members only). Payment will be determined by NCQA recognition tier.What is the NCQA’s PPC-PCMH program? NCQA offers a Physician Practice Connections (PPC®) -PCMHTM program to recognize practices as a patient-centered medical home (PCMH). There are nine PPC® standards with 10 “must pass” elements, which can result in one of three levels of recognition. Practices seeking PPC®-PCMHTM recognition complete a Web-based data collection tool and provide documentation that validates responses. Complete details are available at ncqa.org/tabid/631/Default.aspx. In addition, since Priority Health is a sponsor of the NCQA PPC®-PCMHTM program, practices identifying themselves as part of our network receive a 20% discount on their application fee. Keep us informed! The only way we’ll know you’re eligible for the infrastructure support payment is if you tell us. So that we have our systems ready to begin payment to you, we need to know who is applying for the NCQA recognition.
If you’ve already received recognition and/or applied Congratulations! The survey is a rigorous process. It shows your commitment to your patients and to high-quality care. Be sure to let us know when NCQA informs you of your recognition. PharmacyGeneric Drug News
Pharmacy and Therapeutics Committee formulary updateOn November 17, 2009, the Pharmacy and Therapeutics (P&T) Committee met and reviewed several drugs, policies and prior authorization criteria. The following information summarizes the recommendations made at the P&T meeting. It doesn’t represent a comprehensive list of all drugs included on our approved drug list. Please visit priorityhealth.com and click on "Approved Drug List" for detailed information regarding drug coverage.November P&T changes: At a glanceAlphabetized by drug name
ST = Step Therapy • Indicates the change applies to this formulary * indicates drug is covered under the medical benefit P = Preferred Brand NP = Non-Preferred Brand PS = Preferred Brand Specialty NPS = Non-Preferred Brand Specialty T1, T2, T3, T4 = Medicare Tier Designation PPI step therapy
How to obtain a copy of our formularyOur commercial, Medicaid and Medicare formularies are available through our website. To download a copy, go to priorityhealth.com. Click on “Approved Drug List.” Then, click “Get Printable Drug List.”Updated for 2010: We’ve updated the formulary “quick reference guide” that summarizes our coverage of drugs used to treat common conditions. Download and print a copy. Mail order prescriptionsPriority Health members have the option of obtaining their prescriptions from Walgreens Mail Service. The mail service pharmacy will dispense the prescription exactly as you write it. If you write for a 30-day supply, they’ll dispense a 30-day supply. So it’s important to write for a 90- day supply of medication when your patient requests a prescription that will be filled by a mail order pharmacy. Please be certain to provide the following information on all of your prescriptions:
Reduce medication wasteIn an effort to lessen the likelihood of waste associated with prescriptions, we encourage you to be judicious in the quantity of medication prescribed for new medications. While our benefit allows for up to a 90 day supply for commercial and Medicare members, consider writing for less when prescribing a new medication. Why?
Behavioral HealthChanges to the behavioral health authorization processEffective November 1, 2009, in order to help our members receive an initial evaluation more quickly, we no longer require a behavioral health provider to be identified in the authorization.Courtesy faxes and online access to authorizations have been discontinuedBecause the member doesn’t have to select a behavioral health provider before we issue authorization, we don’t know who they have chosen. This means we can no longer send you a courtesy fax before the initial evaluation. It also means the authorizations will not be available on our website. To confirm authorization, call the Provider Helpline at 800 942-4765. Members still do obtain authorizationMembers are still required to contact Priority Health to get authorization for their initial evaluation. If a member doesn’t get prior authorization for an initial evaluation it is a member liability. Please direct members with questions to our Customer Service department at the number on the back of their ID card.Questions? Call us. If you have questions about prior authorization, please contact the Provider Helpline at 800 942-4765. Substance abuse medical necessity updateEffective December 1, 2009 we implemented the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC) for the treatment of substance-related disorders. This is the most widely used and comprehensive set of guidelines for placement, continued stay and discharge of patients with alcohol and other drug problems.Medical necessity criteria American Society for Addiction Medicine (ASAM) Prior authorization remindersWe would like to remind you that outpatient mental health and substance abuse therapy sessions do not require prior authorization. This means you will not need to call us to approve outpatient mental health or substance abuse therapy sessions for 2010. Please note that Priority Health members are still required to obtain prior authorization for initial evaluations for counseling, psychological testing and psychiatric medication management. In addition, authorization isn’t needed beyond the initial evaluation for counseling, psychological testing, psychiatric medication management and substance abuse intensive outpatient therapy.Priority Health has also made two changes to our inpatient authorization processes that will positively impact your facility. Both changes became effective November 1, 2009.
Behavioral health benefits information available to providersAs of January 13, 2010 behavioral health copays and coinsurance details for Priority Health members are available through our online Member Inquiry tool. In Member Inquiry you can see by member this information for inpatient and outpatient services.Information available for benefits effective January 1, 2010 This Member Inquiry update will show behavioral health copays and coinsurance for members with plans effective January 1, 2010 and after. If a member has Priority Health coverage today, but their plan renews July 1, 2010, their behavioral health related information will not show in our Member Inquiry tool until July 1. Accessing our online tools Need a provider account? No problem. Just go to priorityhealth.com/provider and select “Register Now.” Questions Contact the Behavioral Health department at 800 673-8043. Questions?If you have questions about information in this edition of Physician and Practice Information, call your provider account representative, provider account coordinator or the Provider Helpline at 616 942-4765 or 800 942-4765.
Last modified
02/04/10
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February/March 2010
Physician and Practice Information
