Complete Story
04/22/2025
Priority Health Update
Priority Health Managed Care Committee Member
Flora Werle - The Cancer & Hematology Centers
Click here to visit the Priority Health Provider News Page for additional updates.
Update to Corrected Claims Goes Into Effect June 2
Effective June 2, 2025, all submitted claims requiring a correction – both facility and professional, regardless of any allowed / paid amount on the original claim – will require submission of a corrected claim with frequency code 7.
Authorization Appeal Effective June 2
Effective June 2, 2025, we won’t review post-claim appeals for medical necessity when a denied authorization is on file for the following authorization types, for all lines of business:
- Outpatient, home health & DME
- Elective inpatient
- Behavioral health
Note: This change doesn’t apply to inpatient acute / urgent / emergent or post-acute authorizations.
Authorization Requests for Diagnostic Imaging Procedures 73700 and 73200 Now Auto Approve
Authorization requests for the following pre-operative diagnostic imaging procedures are now set to auto approve:
- 73700: Computed tomography, lower extremity; without contrast material. Under diagnostic radiology (diagnostic imaging) procedures of the lower extremities
- 73200: Computed tomography, lower extremity; without contrast material. Under diagnostic radiology (diagnostic imaging) procedures of the lower extremities
These imaging procedures previously required documentation of an approved surgical procedure for medical necessity review.
We hope this change will help improve your workflow, reduce your administrative burden and support you in getting your Priority Health patients the care they need when they need it.
Updated 2025 PCP Incentive Program (PIP) Manual Now Available
We recently made the following update to the 2025 PCP Incentive Program (PIP) Manual:
Care Management codes (pg. 20-21)
The code table has been corrected to reflect the following:
- Claims with codes G9008, 99484 and 98966 will serve to identify Medicare members that have received care management services and will count toward the 2% target. These codes were previously incorrectly unchecked for Medicare.
- Code G0512 is valid for the full program year (rather than through June 30, 2025, as previously indicated in the manual).
Access the manual through our Provider Incentives webpage (login required).
We'll Use 2025 InterQual Criteria Starting June 2
Beginning June 2, 2025, we’ll use 2025 InterQual® criteria to make medical necessity determinations on prior authorization requests to ensure our members are getting the right care, at the right place and at the right time.
Why are we updating to 2025 InterQual?
InterQual is nationally recognized as an industry standard for evidence-based medicine criteria, ensuring appropriate care. These criteria are regularly updated to reflect the most recent evidence-based and clinical standards.
We're Collecting Records for Our Medicare Retrospective Chart Review
Beginning April 22, our Risk Adjustment team in partnership with Datavant, a health information technology company, will be contacting select providers to request medical records for our Medicare retrospective chart review. This review helps us to validate our members’ diagnoses and ensure the risk adjusted payments we receive from the Centers for Medicare and Medicaid Services (CMS) are accurate.
What do you need to do?
If you’re contacted by Priority Health or Datavant, please submit the requested documentation by the deadline provided in your communication.
IV Fluid Shortage: Temporarily Allowing Subcutaneous Administration
Update 4.14.25 - With the IV fluid shortage coming to an end, we'll reinstate our standard IV fluid billing and payment rules for both inpatient and outpatient facilities on June 1, 2025.
Guidance on Coding and Submitting Documentation for Exclusion Conditions in a Virtual Visit for the SUPD and SPC Measures
To support gap closure in the Statin Use for Persons with Diabetes (SUPD) and the Statin Therapy for Persons with Cardiovascular Disease (SPC) HEDIS measures, we’ve added guidance on coding and submitting documentation for exclusion conditions during a virtual visit to our SUPD and SPC provider tipsheets, along with a complete list of all exclusion codes for these measures.
You can download our provider tipsheets below or find them on the Quality Improvement page in prism. The updates to these documents were also applied to Appendix 6 in our 2025 PCP Incentive Program (PIP) manual.
National Prescription Drug Take Back Day April 26
We’re pleased to participate again in National Prescription Drug Take Back Day on Saturday, April 26, 2025. We invite your patients and all community members to drop off their expired, unwanted, or unneeded prescription medications for safe disposal from 10 am – 2 pm at one of the locations listed below:
New and Updated Billing Policies Now Available
We publish billing policies to offer transparency and help providers bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
The following billing policies were recently published to or updated in our Provider Manual. See each individual policy for details.
- Ambulatory surgical centers (new)
- Balance billing (new)
- DME POS (updated)
- DME refill requirements (new)
- Drugs administered by providers for FDA-approved or medically accepted off-label uses (new)
- Genetic testing (updated)
- Hospice care (new)
- Ordering / referring provider requirements (new)
- Surgical dressings (updated)
New and Updated Billing Policies Now Available
We publish billing policies to offer transparency and help providers bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
The following billing policies were recently published to or updated in our Provider Manual.
Note: If the effective date is listed as “N/A”, the policy represents our current system set up and expectations for transparency. There are no changes for providers as the policy is already in effect.
|
Policy |
New or updated |
Description |
Effective date |
|
Updated |
This policy primarily compiles guidelines already present in our online Provider Manual and that are already in effect. With the publishing of this policy, we added guidelines for taxonomy codes that will go into effect on May 19, 2025. |
May 19, 2025 (taxonomy codes only) |
|
|
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) |
New |
This policy defines billing, reimbursement, and documentation guidelines for Cardiac Event Detection (CED) and Holter Monitoring (24-hour ECG monitoring). |
N/A |
|
New |
This policy defines our current reimbursable limitations and documentation requirements associated with flow cytometry. |
N/A |
|
|
New |
This policy identifies the billing and documentation requirements associated with Magnetoencephalography (MEG). |
N/A |
|
|
Updated |
Added information on seat lift mechanisms |
N/A |
|
|
New |
This policy identifies the payment and documentation requirements associated with oxygen and oxygen supplies. |
May 19, 2025 |
|
|
Updated |
|
May 19, 2025 |
|
|
New |
This policy defines billing, reimbursement, and documentation guidelines for semiprivate rooms and private rooms for patients in a hospital setting. |
N/A |
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