We’re no longer allowing providers to be enrolled under multiple ACN contracts with the same NPI, TIN and address.
Effective July 8, 2024, we’ll no longer allow providers to be enrolled under more than one ACN contract at a time under the same NPI, TIN and address. This includes ACNs with both direct and delegated contracts.
Background
ACNs enroll their providers with Priority Health through prism (direct) or through a SharePoint submission process (delegated). If an ACN is requesting to enroll a provider that's still enrolled with another ACN, we have been leaving the provider enrolled under the original ACN’s contract, adding the new ACN enrollment as an alternate and sending a letter to request the provider update their enrollment with us.
For example: Dr. Jane Smith is an in-network provider, enrolled with Beaumont ACO. OSP submits an enrollment request in prism for Dr. Jane Smith using the same NPI, TIN and address as her current enrollment. In our system, Dr. Smith is now enrolled under both Beaumont ACO and OSP, Beaumont being primary, and our teams send a letter directly to Dr. Smith to determine which group is primary.
What’s going to change on July 8?
On July 8, 2024, our system will automatically update to enroll providers under the contract of ACN that last requested them.
Continuing from the example above: Dr. Jane Smith is enrolled under Beaumont ACO and OSP. On July 8, Dr. Smith will only be enrolled under OSP.
Why we’re making this change
Allowing providers to be enrolled under multiple ACN contracts using the same NPI, TIN and address has led to:
- Pricing issues as the provider is enrolled under multiple ACNs
- Inaccurate reporting as we are unable to pull accurate rosters for providers if their ACN isn’t accurate in our system
- PRA issues because of inaccurate ACN listings
Member impact
If a member had been covered at in-network or first-tier levels with a provider solely because of that provider’s previous enrollment status, they may no longer be covered at those levels at this provider after this change. This should only be an issue with narrow network and tiered network plans, and as long as members are seeing providers who meet specific network inclusion criteria, it won’t be an issue.
What else do PHOs / POs need to know?
The provider will not be notified of a change to their enrollment via letter or email. If they would rather be enrolled under the contract of a previous ACN, they should reach out to that ACN to have them resubmit an enrollment request or open a prism inquiry.
This update won’t impact the data stored in our Provider Roster Application (PRA) tool. ACNs will still need to negotiate the provider in question’s release from their current ACN for value-based program roster management.
For assistance with this, ACNs should reach out to their PSS consultant.