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. Visit our authorizations page for instructions on how to request in-network and out of network authorizations. 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,
Medicaid claim requirements
Medicaid is always the payer of last resort. When a Medicaid member is also covered by another payer, the Michigan Department of Health and Human Services (MDHHS) requires other payers be:
- Billed first
- Identified properly on the claim (see details below)
How to ensure your claims get paid
- Ensure that ALL applicable Other Insurances are listed on the claim. You can find this information in CHAMPS.
- Ensure that all required data elements are present for each Other Insurance listed on the claim.
Below in bold are the required data elements by loop. Elements identified with an * are situational and only required in certain circumstances.
Loop ID - 2320 - Other Subscriber Information
- SBR - Other Subscriber Information*
- CAS - Claim Level Adjustments*
- AMT - Coordination of Benefits (COB) Payer Paid Amount*
- AMT - Remaining Patient Liability*
- AMT - Coordination of Benefits (COB) Total Non-Covered Amount*
- OI - Other Insurance Coverage Information
Claim Filing Indicator Code
Yes/No Condition or Response Code
Release of Information Code - MIA - Inpatient Adjudication Information*
- MOA - Outpatient Adjudication Information*
Loop ID - 2330A - Other Subscriber Name
- NM1 - Other Subscriber Name
- N3 - Other Subscriber Address*
- N4 - Other Subscriber City, State, ZIP Code
- REF - Other Subscriber Secondary Identification*
Loop ID - 2330B - Other Payer Name
- NM1 - Other Payer Name
Entity Identifier Code
Entity Type Qualifier
Name Last or Organization Name
Identification Code Qualifier
Identification Code - N3 - Other Payer Address*
- N4 - Other Payer City, State, ZIP Code
- DTP - Claim Check or Remittance Date*
- REF - Other Payer Secondary Identifier*
- REF - Other Payer Prior Authorization Number*
- REF - Other Payer Referral Number*
- REF - Other Payer Claim Adjustment Indicator*
- REF - Other Payer Claim Control Number*
There may be certain circumstances where Other Insurance may not be applicable but should still be listed. We're constantly reviewing our procedures and code lists and conferring with MDHHS about discrepancies. However, we must still require providers to list Other Insurance in these circumstances until further notice.
Medicaid edit 21007
In January 2021, MDHHS implemented Medicaid edit 21007 which rejects claims that don't meet the criteria listed above.
In November 2021, we instituted our own edit 21007 to front-end reject these claims as well. If the edit identifies another payer based on a membership list provided by the State, and that payer isn't identified on the claim with all the information the state needs, it rejects the claim with the following message:
"Beneficiary Has Other Insurance so providers Must Submit Other Insurance Payer Information on the Encounter"
If your claim is rejected due to edit 21007, follow the steps in How to ensure your claims get paid above before resubmitting a corrected claim.
Medicaid edit 5169
Make sure the "Primary Specialty" field in your CHAMPS enrollment form is complete and an approved provider type. Pay close attention to the provider types you enter into the Attending, Referring and Ordering fields for Medicaid claims. Medicaid edit 5169 rejects claims for "non-approved provider types." Below are the allowed provider types per Medicaid policy: