Q2 physician and practice news digest
Help your patients prepare for the end of the Public Health Emergency (PHE)
By: Dr. David Rzeszutko, MD, MBA, Vice President, Medical and Clinical Operations
Let's work together to offer your patients, our members, support as the PHE ends May 11, 2023.
COVID-19 coverage changes
The PHE allowed for member cost share flexibility within their health plan for COVID19 related claims. The end of the PHE will mark several cost share and coverage changes for testing, vaccines and more.
See our recent news item that outlines the changes taking place on May 12.
All providers must revalidate their Medicaid enrollment information
To continue being reimbursed for the services you provide, you must revalidate your enrollment information at least once every five years, or more often if requested by MDHHS. MDHHS will notify you when revalidation is required. We encourage you to keep an eye out for this communication.
See MDHHS’s CHAMPS Instructions & Information.
Medicaid redetermination requires all members to renew.
The state of Michigan is restarting full eligibility reviews for D-SNP, Healthy Michigan and Medicaid members in June 2023.
- To ensure you get paid, check your Medicaid patient’s coverage prior to providing services. Members may lose coverage if they didn’t renew their information or if they couldn’t be contacted during their Medicaid re-enrollment period.
- If a member no longer has Medicaid coverage and believes they still qualify, they’ll need to reapply through their account, by calling the Medicaid Beneficiary Hotline at 1.800.642.3195 or by visiting their local MDHHS office.
- If a member is no longer eligible for Medicaid after a full renewal, they’ll receive information on when enrollment ends, how to appeal and how to enroll in other health coverage.
Learn more about Medicaid redetermination on the MDHHS website.
Thank you for all you do,
Dr. David Rzeszutko, MD, MBA
Vice President, Medical and Clinical Operations
Billing and coding tips
We recently hosted a Virtual Office Advisory (VOA) webinar specifically for billers and coders covering a variety of topics from top denial reasons of 2023 and how to avoid them to appeals tips for non-contracted Medicare providers, and more. Below are a few highlighted tips.
Use prism as your source of truth for denials
prism shows exactly why a claim was denied, along with any potential clinical edit denial information including Local Coverage Determinations (LCD) or Noncommunicable Diseases (NCD) information. In contrast, 835 files only provide generic denial information.
Use one claim line for multiple observation (G0378) units 0378 should be on one claim line with total units on UB-04 Bill Type 013X or 085X claims to prevent the following edit:
- APC Edit 051: Observation code G0378 not allowed to be reported more than once per claim (Returned to Provider (RTP)
Download remittance advice files within 90 days
Remittance advice (RA) files are available in Filemart for 90 days. After 90 days, we archive them and are unable to process requests to retrieve them. It’s the provider’s responsibility to:
- Download the files.
- Share them with third-party billing companies as needed.
- Store them for the federally mandated 5-7 years.
If you need access to Filemart to download your RA files, you’ll need to gather the tax ID and NPI number(s) for all providers you’ll need access for, then:
- Log into your prism account.
- Click General Requests then New Request.
- Select the Website Tools & Services option.
- Click Next, twice.
- Enter in the message box: “Please provide Filemart access to the following tax ID numbers and NPI numbers: (list them individually)”
- Click Submit.
Complete billing within 12 months
Providers have 12 months from the date of service to complete billing and resolve claim discrepancies. This is our timely filing limit.
- We’ll deny corrected or augmented information received after 12 months to provider liability.
- We won’t override our timely filing limit for front-end rejected claims because they don’t enter our payment system and aren’t considered clean claims
Medicare & Medicaid quality
Together, we can 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.
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 recognize the hard work you do to keep our members healthy. Below are key incentive program updates and deadlines for the second quarter of 2023.
2023 PCP Incentive Program (PIP)
Quarterly estimated pre-payments help us support our ACNs to maintain stability year-round. Our first chronic disease focus measure pre-payments were delivered to participating Accountable Care Networks (ACNs a.k.a. CINs, POs, PHOs and group practices) in April.
Future pre-payments will be issued in late June, September and December.
Our 2023 chronic disease focus measures are hypertension and A1c ≤ 9.0%.
We encourage you to report results either via CPT® II codes or through a direct data feed. If you’re performing A1c tests within your office, and you don’t report a value with the test that automatically scores the member as >9%.
Details on these measures and the payment/settlement methodology are in our 2023 PIP manual.
2023 reports: Work with your ACN
PIP reports will be delivered at the ACN level, meaning practice groups won’t see PIP reports in Filemart for the performance year. Your ACN is your source for all quality/PIP reporting, including gaps in care.
Not sure whether your practice group is part of a qualified ACN or need help reaching out to your ACN? Contact our value-based programs team PH-PartnersinPerformance@priorityhealth.com.
2022 PIP settlement
Contracted ACNs will receive settlement for the 2022 program year for all their member providers in one check on or around June 1, 2023. ACNs are responsible for distributing these settlement funds and reporting to providers at their discretion. Our Provider Strategy & Solutions Consultants will email remittance reporting.
Provider Roster App (PRA)
In mid-March, we updated the Provider Roster Application (PRA) tool to allow ACNs to edit Group NPI numbers. Interested in learning more about the PRA tool and how it works? Get the 2023 PRA Manual.Important dates
Mark your calendars for this quarter’s important dates:- May 1-15 – PRA attestation
- June 1-15 – PRA attestation
- Late June – 2nd focus measure pre-payment
- July 1-15 – PRA attestation