2011 December/January - Physician and Practice Information
Maximize your income — and help your patients get optimal care — with our Partners in Performance (PIP)
incentive program that rewards primary care physicians for providing excellent care and great experiences
while managing costs.
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Remember to run a “Care Opportunities” report in the Health Conditions section of Patient Profile in
December to capture 2- and 13-year-olds who need immunizations in early 2012. Immunizations must be
up to date on or before the child’s birthday in order to meet the PIP requirements.
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A provider may request exclusion of a member for the 2011 program year at any point prior to
Dec. 31, 2011.
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Review your Patient Profile or supplemental data reports and schedule mammograms for those women not
yet meeting this measure for 2011.
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Read about these upcoming data submission deadlines.
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Although we accept data until the end of February 2012, monthly PIP reports for the 2011 program year end
in January.
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We're excited to introduce a new tool for providers that will show you how clinical edits will be applied to future
claims, and how edits have been applied to processed claims.
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Priority Health has reviewed current evidence and guideline statements surrounding preventive health care to
prepare for releasing our 2012 preventive health care guidelines.
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If you need to change your password on your Priority Health provider account, follow these instructions.
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In 2012 we’re adding some new plan designs that support patient care by encouraging members to seek
preventive care and manage chronic conditions.
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Several claims deny each week because of insufficient information to process the unlisted service
(e.g., lack of medical notes, inability to identify unlisted services, etc.). Here are three helpful tips to
get unlisted codes processed on the first submission.
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A key component to patient satisfaction is the establishment of a trusting relationship with a provider.
Sometimes patient and provider relationships can become strained. Dealing with patient and provider
issues in a constructive and professional manner is the best way to maintain positive patient relationships.
Priority Health wants to make sure that our providers are informed about the concerns patients express.
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Doctors and other health care professionals work with Priority Health to provide preventive care, control
chronic conditions and deliver an exceptional experience to their patients. We congratulate these
outstanding offices for making health care more accessible and affordable in our community.
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Every year we like to remind you of the plan information and programs available to you.
The listings here highlight these areas and direct you to more information available online.
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Starting Jan. 1, 2012, select insulin products will be available on the employer-sponsored
(commercial) formulary for a generic copay!
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Priority Health has a generic substitution policy that mandates coverage of generics when an
A-rated or equivalent generic is available. Currently, if a member or physician requests the brandname
product, the member may have to pay the difference in cost between the brand and
generic drug cost, plus their copay. This is known as member pay difference (MPD).
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On Nov. 15, 2011, the Pharmacy and Therapeutics (P&T) Committee met and reviewed several
drugs, policies and prior authorization criteria.
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Effective Jan. 1, 2012, high-risk medications (HRMs) will be removed from the Priority Health
Medicare formulary.
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Please make sure your patients who are 65 or older, especially those who have an underlying
condition or respiratory disease, have had a pneumonia vaccine.
» Read more
