Complete Story
06/15/2023
Priority Health Update
Priority Health Managed Care Committee Member
Flora Werle - Cancer & Hematology Centers of West Michigan
Reminder: Use a Street Address for the Billing Provider Address on Claim Form 1500
Per HIPAA standard, the Billing Provider Address field on claim form 1500 (item 33) must be a street address. We occasionally see Medicaid claims – both paper and EDI – with a P.O. Box* address in this field, which isn’t allowed.
How we’re addressing the issue
- Currently, payments for claims found to have this error will be recovered. Providers can rebill with the appropriate address information.
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In the future, we hope to implement an edit which will front-end reject claims with this error back to the provider.
What you can do
To avoid claim adjustments due to this error, make sure the Billing Provider Address field on your 1500 claim forms contains an appropriate street address.
*P.O. Boxes are allowed only in the Pay-To address field on the claim form 1500.
Out-of-Network Provider Surprise Billing Payment Disputes
According to Michigan law, out-of-network providers aren't allowed to send patients surprise bills. Surprise billing, or balance billing, has never been allowed for participating providers.
Surprise billing happens primarily when a patient receives care at in-network facility but the provider may not be contracted with the insurance carrier and is considered an out-of-network provider.
See our surprise billing webpage for details on the information out-of-network providers are required to give non-emergency patients.
Surprise billing payment disputes
If an out-of-network provider disagrees with how they’ve been reimbursed related to surprise billing, they have the right to initiate a 30-day open negotiation period.
To initiate an open negotiation period, send an email to provider.services@priorityhealth.com including your name, phone number, and message. Be sure to attach the required open negotiation letter, including a description of the item(s) or service(s), claim #, provider name, and NPI along with dates of service.
InterQual is Operational, Our Normal Prior Authorization Processes Have Resumed
InterQual, operated by Change Healthcare, experienced a brief, national outage beginning June 8. As of this morning, it's back up and running, and our normal prior authorizations procedures have resumed.
Providers may experience some slowness throughout the day as Change Healthcare absorbs volume and re-optimizes traffic.
Medicaid Claims Rejection Issue Resolved
Recently, some Medicaid claims were incorrectly rejecting for “Claim Type Required a Referring/Ordering NPI” when they shouldn’t have. This issue started on May 23 and was resolved on May 30.
All impacted claims have been reprocessed. There’s no need to rebill.
Two New Chronic Pain CM Codes Now Covered for Our Medicare and Commercial Members
On Jan. 1, 2023, CMS released two new care management codes for chronic pain management – G3002 and G3003 – which allow providers helping chronic pain patients to bundle key services and bill monthly rather than a’ la carte.Effective Jan. 1, 2023, we’re covering these codes for our commercial, individual / ACA and Medicare plans, including D-SNP.
What do these codes cover?
Any provider helping a Priority Health member manage their chronic pain through the services listed below may use these codes.
G3002
Chronic pain management and treatment, monthly bundle including:
- Diagnosis
- Assessment and monitoring
- Administration of a validated pain rating scale or tool
- Development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes
- Overall treatment management
- Facilitation and coordination of any necessary behavioral health treatment
- Medication management
- Pain and health literacy counseling
- Any necessary chronic pain related crisis care
- Ongoing communication and care coordination between relevant practitioners furnishing care e.g., physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate
G3003
Each additional 15 minutes of chronic pain management and treatment by a physician or health care professional able bill Priority Health, per calendar month. List separately in addition to code for G3002. When using G3003, 15 minutes must be met or exceeded.
Additional details
Below are a few important billing details related to these new codes:Both codes can be billed virtuallyG3002 can be billed once per calendar monthG3003 can be billed as many times per calendar month as medically necessary once G3002 is billedBoth codes can be billed with other codes, including procedure codes, E/M codes and other care management codes.
May 2023 Medical Policy Updates
Our Medical Affairs Committee (MAC), comprised of network practitioners contracted with Priority Health, meets quarterly to review a set of our medical policies. The policy changes outlined below were approved by MAC at the May 10 meeting and – unless otherwise noted – are effective May 2023.
Click here to visit the Priority Health Provider News Page for additional updates.
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