Q4 physician and practice news digest

Keeping quality at the forefront

By Richard Vienne, DO, VP, Medical and Clinical Operations

As we look forward to transitioning into a new year, one thing will remain the same – our commitment to offering our members, your patients, the best affordable care possible. We accomplish this by partnering with you to drive quality success in offering the right care, at the right time, in the right place and at the right cost.

As a health plan, we’re measured by our quality performance and we’re happy to share that our Medicare HMO-POS contract received its first 5-star rating, the "excellent” standard for quality and performance. Thank you for all the work you do that contributes to our star ratings. When we receive higher ratings, we’re able to offer richer benefits to remove cost and access barriers for your patients when delivering care.

Let’s continue working together to close gaps in care and improve the well-being of our community as we enter another year.

Below are some quality metrics we need your continual support in.

Controlling blood pressure

  • Patients with hypertension should be seen on a regular basis and have their blood pressure taken at every visit – preferably twice as best practice.

Diabetic retinal eye exam

  • Encourage your patients with diabetes to get their Diabetic Retinal Exam.
  • These exams are a crucial monitoring aspect of diabetes that can help prevent deterioration of vision or potential blindness.
  • Referrals aren’t required for this screening.


  • Immunization rates are dropping across Michigan every year. It’s critical to educate parents on the importance of routine childhood immunizations.

Lead screenings

  • We’re always tracking lead screening performance to ensure these services are taking place. Over the last three years, we've seen a decline in lead screenings that are completed before a child’s 2nd birthday.

Thank you for the care you provide our members with to help them reach their health goals.

Best wishes,

Richard Vienne, DO

Billing & coding tips

Setting up electronic claim/RA file sharing

Visit our Provider Manual’s EDI setup page to learn about:

  • Electronic data interchange (EDI) setup
  • Transaction types available for EDI
  • Real-time transaction exceptions

Download your remittance advice files from Filemart within 90 days

After 90 days, requests for archived remittance advice files won’t be accepted

  • Save the files to your internal servers within 90 days
  • Share the files with third-party billing companies as needed
  • Maintain the files for the federally mandated 5-7 years

Resources for prism

Visit our Provider Manual’s prism resources page to learn about:

  • How to register for prism or create an account
  • Managing your group or facility
  • Managing claims and appeals
  • How to enroll a provider, make changes and track status
  • Using our digital navigation assistant
  • How to submit questions using prism’s General Requests feature

Contact us about a specific claim

Follow the process below to send us a message about a specific claim:

  • Log into your prism account
  • Open the Claims menu and click Medical Claims 
  • Type the claim number in the box that says Specific Claim Search, then click Search
  • Click the Claim ID to open the Claim Details page
  • Click Contact us about this Claim
  • Follow the listed prompts to submit your inquiry

Don’t use General Requests to submit an inquiry about an existing claim. We’ll close any inquiry submitted incorrectly and notify the sender to resubmit correctly.

When to submit a corrected UB04 claim or a new UB04 claim

  • Submit a correct claim if there’s any type of payment on the claim, member liability was processed on the claim or if you’re appending a modifier not submitted on your original claim
  • Submit a new claim if the entire claim was denied or if no payment was made on the original claim

90-day grace period

When we make or recover payments near or after our filing limit, you have 90 days from the date on the Explanation of Benefits (EOB) to submit the claim to us. Payment corrections from another health plan require the claim and EOB to be submitted to us.

Submitting takeback EOB information doesn’t require an appeal. If you’re within the 90-day grace period, open the claim in question in prism, click Contact Us about this Claim and use the Other Related Claims Questions drop down option, attaching relevant documentation before submitting. This ensures your inquiry will reach the right department for faster review

Helpful tips

  • Attach the EOB to the claim so we can verify the claim was submitted to us within 90 days.
  • If you don't follow-up within 90 days, we’ll deny requests without appeal rights.
  • We’ll deny revised information received after the 90 days to provider liability.
  • Denials related to authorizations/medical necessity or coding/clinical edits still follow the filing limit rules.
  • We won’t make exceptions to this policy for overlooking a claim or response deadline

Medicare & Medicaid quality news

Together, we can continue to close your patients’ gaps in care. From preventative screenings to managing chronic conditions, we’re here to support you. Get information on our latest Medicare & Medicaid quality information, provider tools and member benefits

Download the guide

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 fourth quarter of 2022.

PCP Incentive Program (PIP)

We’ve redesigned and rebuilt our PCP Incentive Program (PIP) from top to bottom for 2023, ushering in opportunities to earn incentive payments more frequently throughout the year. Starting in January, you’ll:

  • Engage more deeply in specific measures
  • Get more targeted data
  • Receive incentive payments both quarterly and at year-end 

Latest news

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