West Michigan Partners remediation Oct. 1, 2018

After hearing provider feedback on better identifying West Michigan Partners members, and accurately calculating cost sharing, we're planning some enhancements. Starting Oct. 1, 2018, tool improvements will alleviate confusion in navigating tiered network benefits, and improve the provider and member experience.

As part of the project, it was determined that five major problems needed fixing:

Problem:  Provider offices over-charging member copays due to real time eligibility processes

Solution: A vendor has worked on a solution with Spectrum Health and Priority Health to explore process and training opportunities

Problem:  Provider office cost-share confusion

Solution:  The Priority Health provider portal update adds provider location and provider name to populate the proper tier level

Problem:  Member experience/compliance

Solution:  Change the PCP assignment model by assigning tier 1 PCP to members without an existing PCP, and change the PCP search radius to 30 miles

Problem:  Customer experience overall

  • Solution:  Update to the member portal to break out medical and behavioral health benefits
  • Solution:  Align the provider portal information to be available in an eligibility file (271)
  • Solution:  Align employer, provider and member portals to the same medical benefit brick

Problem:  Provider experience overall

Solution:  Update the 271 requirement to return eligibility information by name and DOB rather than only member ID number 947