Medicaid billing

Medicaid participation

If you are not currently contracted with the Priority Health Medicaid product, Priority Health will reimburse you at the Michigan Medicaid fee schedule for covered services. Prior authorization may be required. You may not balance-bill the member.
Go to the Michigan Medicaid fee schedule on the State of Michigan website.

New vs. established patients:

See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.7

Medicaid claim resubmissions

Prior to Jan. 7, 2019, Providers were allowed to resubmit claims subject to a third-party liability (TPL) investigation only after Priority Health had received no response from the patient for 180 days. This was called the "180-day rule." On or after the 180th day after the claim denial, the Provider could resubmit the Medicaid patient claim or verbally request that the claim be reprocessed for payment. The 180-day rule didn't apply to claims denied due to TPL for the situations listed below:

  • Coordination of Benefits
  • Motor vehicle accidents
  • Workers Comp
  • School-related injuries

As of Jan. 7, 2019, Priority Health made changes to eliminate the 180 day rule. When Providers submit a Medicaid claim that requires TPL review, the claim will be pended, reviewed and paid if no other liable parties are identified. Claims will continue to deny if our review determines there's another primary payer, including motor vehicle, worker's compensation or school-related injuries.

Any open claims previously denied by Priority Health for the Medicaid "180-day rule" may be resubmitted at your convenience for payment consideration.

1450 - Facility claims

  • Submit a corrected claim with the appropriate bill type, changing the frequency (third digit of the bill type) to reflect the change.
  • Priority Health will adjust the original claim, denying all service lines as charges billed in error.
  • Priority Health will then process the new claim for payment.

1500 - Professional claims

  • Submit a corrected claim with the appropriate billing code.
  • Priority Health will adjust the original claim, denying all service lines as charges billed in error.
  • Priority Health will then process the new claim for payment.

Effective January 1, 2018

All providers furnishing services to Michigan Medicaid beneficiaries, including providers participating in a managed care organization’s provider network, are required to be screened and obtain active enrollment in the Michigan Medicaid program. The purpose of this requirement is to strengthen the Medicaid program integrity by preventing provider fraud. 

Enrollment is completed through Community Health Automated Medicaid Processing System (CHAMPS)—the state’s web-based Medicaid enrollment and billing system. 

For more information about the provider enrollment requirement, view the MDHHS Medical Services Administration Provider Bulletin 17-48.

For information about the Provider Enrollment process, visit the MDHHS Medicaid Provider Enrollment page. Providers who have questions about the enrollment process or require assistance, may contact the MDHHS Provider Enrollment Help Desk at 800.292.2550.