Medicaid, MIChild and CSHCS patients

Priority Health is a Qualified Health Plan for West Michigan. Medicaid pays for medical assistance for individuals and families with low income and resources.

ID cards show Priority Health Choice MDC

The State has instructed us not to use the word "Medicaid" on member ID cards. Therefore, our ID cards show the plan name as Priority Health Choice MDC.

Authorizations

To see what services require prior auth, go to the authorization reference list in this manual.

Billing for services for Medicaid patients

You must use the subscriber ID (including the two-digit suffix), NOT the Social Security number, to identify the patient on both electronic and paper claims. Claims submitted without a valid subscriber ID or Medicaid ID number will be rejected.

Go to the "How to bill" section of this manual.

Eligibility & enrollment

Medicaid eligibility is determined at the local Department of Health & Human Services (DHHS) office. A DHHS worker reviews the beneficiary's financial and non-financial information (e.g., disability, age, etc.) and determines type of assistance for which beneficiary is eligible. Once eligibility is established, data from DHHS is available via the CHAMPS Eligibility Inquiry, and a mihealth card is issued for new beneficiaries.

Enrollment is "rolling." The last digit of the case/contract number indicates the open enrollment month for the beneficiary: 2 = February, for example. Coverage usually is effective the first day of the month in which the beneficiary becomes eligible. Exceptions:

  • Coverage may begin the actual day the beneficiary becomes eligible
  • Beneficiary may be retroactive up to 3 months prior to the month of application if all eligibility requirements for the specific health care program were met and medical services were rendered.

If the individual does not voluntarily choose a managed Medicaid plan within 30 days, he/she will automatically be assigned by the State to a managed Medicaid plan available in the person's county of residence.

New Medicaid managed enrollees have 90 days from the date of enrollment to the initial managed Medicaid plan to switch to another plan. Barring this, they are considered "locked-in" until the next open enrollment period.

To access real-time eligibility log in at: http://healthplanbenefits.mihealth.org/

To apply for access to real time eligibility, go to: http://healthplanbenefits.mihealth.org/modules/application/terms.aspx

Or, call MI Enrolls at 888.367.6557.

CSHCS beneficiaries

Children's Special Health Care Services program beneficiaries are now required to enroll in a Medicaid health plan to receive medical benefits.

  • If a member does not select a Medicaid plan, they are automatically enrolled in one.
  • Members of Medicaid health plans who become eligible for CSHCS will no longer be retroactively disenrolled from their Medicaid plan.
  • Members have 90 days to change plans. After 90 days, benefidiaries are locked in until their open enrollment month.
  • CSHCS members have no copayments, even if they are over 21 years old.

Newborns

  • Newborns may be eligible for Medicaid enrollment for the month of their birth.
  • The mother is required to notify the local DHHS office of the birth of the newborn within 10 days of the birth. OR, the mother can go to www.michigan.gov/mybridges to add their baby to their case online.
  • Newborns are not automatically enrolled onto the mother's plan. The mother must select a plan for the newborn through Michigan Enrolls.
  • If the mother does not choose a plan, the newborn will be assigned to a plan listed in their county.
  • The plan is responsible for all covered services for newborn unless the child is placed in foster care or enrolled in CSHCS.

Reimbursement

We pay Medicaid fees. Go to the Medicaid fee schedules.

Specialty network access

Michigan Medicaid has developed a process and funding for referring patients in need of specialty care access to providers at "public entities" including MSU, Wayne State, Hurley Hospital and the University of Michigan.

Our Medical Authorization Department has fully implemented the SNAF process. All staff members have been trained in how the process works for the use of the Public Entities for Specialty Care. The process is:

  1. All providers referring for specialty care must first exhaust all efforts to find an in-network provider for the member's care.
  2. If no care is available in-network, or the timeline to receive care is too long and the member's need is critical, and if the in-network provider cannot accommodate the member's need, we allow them to use the SNAF process and contact the public entity.
  3. The PCP completes our standard out-of-network referral form and sends it to Priority Health.

    Medical prior authorization form (256KB PDF)

  4. Our Health Management team determines where the referral will go and provides an authorization number to the PCP. MSU subspecialists are generally the first choice due to their central location and business agreement with Priority Health. MSU specialists are listed on the access form.
  5. The PCP completes the access form and forwards it to the appropriate public entity.

    MSU specialty care access form (32KB PDF)

    U of M specialty care access form

Transportation

Call and ask for transportation: 888.975.8102 or in Grand Rapids, 616.975.8102.