Q1 physician and practice news digest

Help your patients battle “winter blues” with our Behavioral Health resources

By: Dr. David Rzeszutko, MD, MBA, Senior Medical Director, Medical Policy

Happy New Year! I hope you enjoyed rest and quality time with your family and friends during the holidays. I’m excited to work alongside you as we embark on another year to improve the health and lives of those we serve.

As we progress through winter, the reality of cold temperatures and shorter days can cause Seasonal Affective Disorder (SAD) or “winter blues” for approximately 5 percent of the U.S. population. Symptoms can include feeling depressed, losing interest in activities, changes in appetite or weight, having issues sleeping and more.*

We’re here to help with mental health care needs year-round.
Our Behavioral Health team is available 24/7 to help you and your patients understand their benefits, provide referrals and assist with urgent mental health needs. Below are resources and initiatives we’ve taken to improve the mental health needs of our community.

  1. Most Priority Health plans include in person and virtual therapy. Call the Provider Helpline at 800.942.4765 or log into prism to get more information on behavioral health services for members. 
  2. All members have access to myStrength, a free, virtual mental wellness tool that features over 1,400 self-directed activities on a variety of mental wellness topics. More than 6,000 members have already taken advantage of this self-help program.
  3. We’re now accepting Licensed Marriage and Family Therapists (LMFTs) into our network. To learn more or join our network, click here

Let’s work together to combat the winter blues and support our members throughout the year with their mental health care needs.


Dr. David Rzeszutko
Medical Director Sr, Medical Policy

Source (nih.gov, 2020)*

Billing & coding tips
2023 fee schedules

We’re in the process of posting 2023 fee schedules, with individual and commercial fee schedules already online. If you’re receiving a claim denial for “Need to rebill as a corrected claim” and you’re billing with a date span, make sure the date span on your claim doesn’t overlap with a previously paid claim. This will prevent unnecessary claim denials and inquiries.

We don’t retroactively adjust any claims paid while we’re loading new rates into our system. To make sure your claims are processed and reimbursed under new rates, you can choose to hold them until you see the new fee schedules posted in prism.

Check for 2023 fee schedules

Durable Medical Equipment (DME) provider billing tips

Billing with date spans
If you’re receiving a claim denial for “Need to rebill as a corrected claim” and you’re billing with a date span, make sure the date span on your claim doesn’t overlap with a previously paid claim. This will prevent unnecessary claim denials and inquiries.

Claim denial: “E3G Required Modifier Not Reported”
To avoid denials for capped rentals (CR), make sure to bill with the appropriate modifiers below:

Either KH, KI or KJ to indicate the timeframe:

  • KH (initial claim, first-month rental)
  • KI (rental months 2-3)
  • KJ (rental months 4-15)
  • And RR (rental agreement) modifier

If an item is listed in the CR category on the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule and is billed without the modifiers above, it’ll deny with reason: “The Service Code Is Inconsistent with The Modifier Used or A Required Modifier Is Missing.”


The following don’t require the KH, KI or KJ modifiers if you’re billing as a “purchase” -- identified with modifier NU (New/Purchase) instead of modifier RR:

  • Complex Rehabilitation Power Wheelchairs (K0835-K0864)
  • Wheelchair Accessories (E0955, E1002-E1008, E1010, E1012, E1020, E1028, E1030, E2310-E2313, E2321, E2322, E2325-E2330, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2378) and K0015, which can be purchased with Complex Rehabilitation Power Wheelchairs

Medicare & Medicaid quality

Annual CAHPS® Survey coming March 2023

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is an annual survey conducted from March to June that assesses member experience with their providers and health plan.

How does it work? Surveys are sent via email to select members during this time frame. Their responses provide valuable insight so we can make enhancements to our programs and products, and provide new patients with information to help them making informed decisions when selecting providers and health plans.

Here's what you can do

Encourage your patients to complete the survey, if selected.

Why is this important to you?

Focusing on a positive patient experience will:

  • Build trust with your patient
  • Improve your patient’s overall wellness and health outcomes
  • Ensure preventive care needs are addressed timely
  • Increase compliance with your clinical recommendations
  • Reduce no show rates

To learn more about CAHPS and how you can improve the patient experience, attend our Virtual Office Advisory on Feb. 9, 2023, where we’ll share CAHPS tips.

Value-based incentive programs

We appreciate your partnership as we work to provide the right care, at the right time, in the right place and at the right cost. We’re continually evolving our incentive programs to help us achieve these goals and to recognize the hard work you do to keep our members healthy. Below you’ll find key incentive program updates and deadlines for the first quarter of 2023.

2023 PCP Incentive Program (PIP)

We've built our 2023 PIP program with three essential components in mind:

  1. Continuing the 2022 model for HEDIS and Care Management, with a few adjustments
  2. Introducing quarterly payments with two chronic disease management focus measures
  3. Collaborating early with ACNs to plan for 2024 and beyond

As a reminder, your 2023 PIP reporting will be at the ACN level only. No practice level reporting will be available. However, you can use the Group & Subgroup feature in our Provider Roster App (PRA) tool to break your reports down by practice group. See below for details. For complete details, see our 2023 PIP Manual and FAQ.

Provider Roster Application 

New in 2023, your ACN can use the PRA tool’s Group & Subgroup feature to add a layer to PIP RPX reports, allowing ACNs to break reports down by practice group. Also new in 2023 is our monthly PRA attestation schedule. Your ACN is now required to attest to its PCP roster at the beginning of each month, reflecting the following month’s roster.

To learn more about the Group & Subgroup feature and to get the 2023 attestation calendar, see our 2023 PRA Manual.

Important dates

Mark your calendars for these upcoming deadlines for the 2022 program year:

  • January 31 – Supplemental data submission deadline
  • February 28 – Claims runout deadline

News & education

Check out the latest news items on our Provider news and education page.