05/19/2021

Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga, Cancer & Hematology Centers of West Michigan

Read These Tips to Ensure Successful Medicaid Billing

We're aligning with the Michigan Department of Health and Human Services (MDHHS) and turning on two front end rejections.

5169: Provider type is not allowed for referring/ordering/attending NPI

The first front end rejection is related to Community Health Automated Medicaid Processing System (CHAMPS) enrollment and provider type. Currently, when a provider submits claims to Priority Health and the referring, ordering or attending provider isn't a medical doctor (MD), doctor of osteopathy (DO), nurse practitioner (NP) or physician's assistant (PA) they will receive a warning. This warning is moving to a front-end rejection starting May 10, 2021. 

This edit will apply to all submitted claims except for tribal health care centers. 
21007: Reject/Adjust due to beneficiary has other insurance so health plan must submit other insurance payer information on the encounter.

Dual Priority Health-Medicaid Secondary

In the past, if a Medicaid claim was submitted without the Priority Health primary explanation of benefits (EOB) information, we would review the claim under the primary contract to obtain the payment information in order to coordinate the Medicaid claim. Due to the State implementing edit 21007, the primary EOB will be required when billing the Medicaid claim.