Q2 physician & practice news digest

Introducing our new PriorityBABY program: all Priority Health babies welcome

David Rzeszutko, MD, MBA
Vice President, Medical and Clinical Operations

Your patients, our members, are at the center of everything we do. That’s why we’re continuously evaluating and enhancing our benefits to ensure we’re meeting the needs of our members at all stages of life.

What is PriorityBABY?
We recently launched PriorityBABY — a premier, family-first program designed to support children and their caregivers during a child’s first two years. It’s a continuation of our successful PriorityMOM™ program and includes educational resources, gifts and incentives for our commercial (group and individual) and Medicaid members with a child under six months old. Members must opt-in to participate in PriorityBABY.

PriorityBABY’s mission
The program helps new caregivers navigate the costs and coverage associated with early child care by:

  • Educating caregivers on appropriate baby health care utilization
  • Preventing unnecessary and costly infant/toddler emergency visits
  • Improving preventive health care utilization for babies, including well-child checkups and vaccinations

What you can do to help:

  1. Inform pregnant members of our PriorityMOM program
  2. Encourage members to enroll in the PriorityBABY program after delivery
  3. Refer members to our customer service team for questions about coverage or benefits

Learn more
Visit our provider manual
or watch our February 2024 Virtual Office Advisory (VOA) to learn more about PriorityBABY, including details about the member journey and more.

Thank you for your continued support in providing your patients, our members, with the exceptional care they need to live healthier lives.

David Rzeszutko

Billing and coding tips

Using provider inquiries, issues and data from the past quarter, our Provider Resolutions and Medical Code Review teams put together this list of tips to save you time and energy with your claims and more.

#1: Visit our new Billing & coding policies page

Our teams are working to publish a series of claims payment policies detailing billing coding and reimbursement guidelines to our Provider Manual.

#2: Know when to submit a new claim vs corrected claim

When you get a claim rejection, it's important to know how to properly resubmit for payment. Resubmitting claims incorrectly can result in further rejections and unnecessary rework.

Follow the guide below to know when to submit a new claim versus when to submit a corrected claim.


Resubmission chart

  • Corrected claims will pend, not deny as duplicate or redundant.
  • Get additional information, including examples of when to use each resubmission type, in our Provider Manual.

Tip: Do you need to have a claim reprocessed due to a contract reimbursement update? Follow the corrected claim process for recalculation.

See more information

#3: Understand Q11 denials on CM claims

You may see a “No compensation allowed for this service – reporting only” denial on some of your care management (CM) claims for commercial* members.

This is simply a notification that the claim will be manually processed. We’ll continue to pay your normal rate for these services, but payment will be batched every 60 days and sent as a paper check.

You’ll see individual remittance advices (RAs) for each submitted claim, where you’ll see the Q11 denial code. This is because we’re applying a $0 initial payment and making the payment “offline” to ensure these important services are covered without member liability.

There’s no need to appeal Q11 denials. If you haven’t received your payment within 90 days, reach out to us through prism.

  1. Log into your prism account.
  2. Find the claim in question under Medical Claims.
  3. Click Contact Us About This Claim.
  4. Select Other Claims Related Questions from the dropdown.
  5. Submit your inquiry.

*Medicare and Medicaid CM services process through our regular claims system.

#4: Use email, not prism, to contact our EDI team

Have a question about your organization’s electronic claim / remittance advice file sharing setup or need to make a change to your setup? Our Electronic Data Interchange (EDI) team is here to help. Contact our EDI team via email at edisetup@priorityhealth.com.

Please don’t use the “EDI Questions” dropdown menu option in prism’s General Inquiries area. This option will soon be removed.

Learn more about EDI setup

Medicare & Medicaid quality

Together, we can close your patients’ gaps in care. From preventative screenings to managing chronic conditions, we’re here to support you. Get our latest Medicare & Medicaid quality newsletter to learn about our Q2 member outreach initiatives, benefit reminders and more.

Download the guide

Incentive programs

Below you’ll find the latest incentive program updates.

PCP Incentive Program (PIP) updates

2023 PIP settlement Our 2023
PIP settlement will take place in June, as it has in previous years. New for the 2023 performance year, settlement will take place at the Accountable Care Network (ACN) level. ACNs will then distribute funds to their practice groups. Reach out to your ACN with any questions.

2023 Quality Awards
We’ll once again award the top physicians in our network through the 2023 Quality Awards. These are awarded following settlement and will go to individual practitioners across the state exemplifying high quality care for our members. Stay tuned for additional details.

2024 Filemart reports
The first 2024 Filemart reports were released earlier this month to ACNs. Information on report updates is available in our Provider Manual. Contact your ACN to receive reporting for your practice.

2025 PIP planning
Planning for our 2025 PIP program is well underway. We’ve been collaborating with network physicians from across the state, representing the following primary care specialties: internal medicine, family medicine and pediatrics. We aim to share the 2025 PIP program updates and manual by July 1.

2024 Disease Burden Management (DBM) program

We know the hard work you put into population health and chronic condition management in your practices. We want to make capturing important information about your patients easier and more efficient so you can focus your time on what matters most – your patients, our members.

Reporting additional diagnoses on claims
Our April VOA highlights how to document all your patients’ chronic conditions when claims forms are limited to 12 diagnoses or fewer.

Watch the recording

Get our DBM one-pager
This resource offers a brief overview of the DBM program incentives and how payment is structured.

Get the one-pager

Learn more about the DBM program

Latest news

Check out our latest news items on our Provider news & education page.