Care management services

Priority Health reimburses, fee for service, for care management services. Reimbursement is available to primary care and specialty physicians. 

Priority Health also offers an incentive for care management when provided by contracted primary care providers who are aligned with an accountable care network. See our PCP Incentive Manual (login required) for additional details.

Eligible patients

To be enrolled in care management, patients:

• Are classified as moderate or high risk based on health history
• Have one or more chronic conditions
• Have a completed care plan that meets documentation requirements

Reimbursement rates

Find reimbursement rates for the codes listed on this page in our standard fee schedules for your contract. Go to the fee schedules.

Billable care management codes

When services are performed on the same date as care management services, the care management services should be coded with the appropriate modifier to reflect a significant, separately identifiable service was performed.

Follow CPT guidelines when billing care management services.

*Exception for codes 98966-98968

We make the following exception for care team members providing telephone services:

The official description of CPT code 98966-98968 states:

“Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment…”

We cover telephone service codes (98966-98968) regardless of:

• Who initiates the interaction
• Whether the patient is new or established
• Whether the service originated from a related assessment and management service provided within 7 days or leading up to an assessment and management service / procedure within the next 24 hours or soonest available appointment

Special payment process for some care management codes

Priority Health has a unique process for paying G-code and telephone visit care management services to prevent member cost share for fully funded commercial, Medicare and Medicaid members.

1. Practices bill care management G-codes and telephone visit CPT services with their practice charges.
2. Priority Health auto-adjudicates claims, applying a $0 payment.

   On the Remittance Advice, the $0 payment yields full allowed dollars as provider liability.

   The Remittance Advice processing code is either Q11 or CO96, "no compensation allowed for this service - reporting only."

   The member's claim explanation displays $0 member liability. No copayment or deductible applies.

3. Every 60 days, Priority Health batches a payment for the full allowed amount of each practice's billed G-codes and CPT codes with no member copayment or deductible.

   These payments are processed "offline" with a paper check.

   The check payment and Remittance Advice report are mailed to the provider's claims remittance advice address.

   A Remittance Advice report designates claim detail such as member demographics, billed codes and date of service.