Reminder: You Must Complete Our D-SNP Model of Care Training by December 31, 2025
Providers play an integral role in the care teams that support our dual-eligible special needs (D-SNP) members. That's why the Centers for Medicare and Medicaid Services (CMS) requires us to make sure providers who are contracted with us to see PriorityMedicare patients are trained on our Model of Care (MOC) every year. 

Our Model of Care is a quality improvement tool that ensures the unique needs of our D-SNP members are met and describes the processes and systems we use to coordinate their care. 

Who needs to complete Model of Care training?  

• All providers who are part of the Priority Health Medicare Advantage network. (All providers contracted with this network must complete the MOC training, regardless of whether they participate in Medicaid.)  
• Out-of-network providers who see at least five D-SNP members

This includes specialists, ancillary providers and anyone part of an ICT (interdisciplinary care team) for a D-SNP member. This is a CMS requirement. 

How to complete training    
Option #1: Bulk attestations   
You can group our D-SNP MOC training with existing, required training (like compliance training) so you can submit attestation for providers at the same time. If you choose this option, you’ll need to:   

1. Distribute training to your providers using this link.  
2. To attest to training, fill out the roster template with providers who’ve received training. Only the Priority Health MOC roster Excel sheet provided will be accepted to report your completion. 
3. Send attestation rosters to DSNPtraining@priorityhealth.com. Please direct any questions to your Provider Network Management specialist, as this inbox is not monitored for questions. 

When an attestation is submitted, one of two automated messages will be sent:     

• A confirmation email stating the roster was successfully processed.
• An email stating the roster wasn’t processed and the reason(s) why.

Option #2: Virtual training (only takes 15 minutes) 
Training is available as an on-demand webinar if you want to complete this training individually. It only takes 15 minutes to complete. Provider registration for the on-demand webinar counts as attestation, which means no additional documentation is required.   

Be sure to submit the correct provider NPI. 

Ensure the correct provider NPI number is included when submitting the provider roster or registering for the online training. If the NPI is incorrect, the provider’s status will be marked "incomplete" in our system. To correct an "incomplete" status due to an incorrect NPI, resubmit the provider roster or re-register for the online training with the correct NPI.   

Training needs to be completed and attested to by December 31, 2025. Late submissions will not be accepted.  

Improved PIP Reporting, New Report Vendor Coming in 2026
We’ll soon be working with a new vendor – CitiusTech – to deliver PCP Incentive Program (PIP) reports to our Accountable Care Networks (ACNs), starting with the 2026 performance year.

Why are we making this change?
With this change, we seek to improve your experience accessing and ingesting your PIP reports. You can expect clearer care gap reporting, supplemental data feed improvements, and consistent delivery of PIP reports via the provider portal – no more email attachments landing in your inbox throughout the month.

Note: This change only impacts PIP reports. Other reports (i.e., Disease Burden Management program (DBM), Alternative Payment Models (APM), Quality) will continue to be delivered as they are currently.

Help us test the new reports
ACNs are invited to test the new PIP reports later this year. If you're interested, let your Provider Network Management consultant know.

More to come
When we’re closer to launch, we’ll offer provider training webinars, covering how to navigate the tool and access/download reports. We’ll also offer written training materials to support a successful transition.

Preliminary 2026 PIP Manual Now Available
After months of planning in collaboration with ACN leaders and network physicians, the Preliminary 2026 PCP Incentive Program (PIP) Manual (login required) is now available.

Note: The manual will be reissued by mid-October with more information and updates. The final manual will be released in early December.

What updates were made?
See page 5 of the manual for an overview of the 2026 program updates, including:

• Administrative changes
• Revised measures
• Retired measures
• New measures

Reprocessing Claims Incorrectly Rejected for "Missing/Invalid NDC" (Medicaid Edit 1462)
We recently experienced a brief issue with some Medicaid claims being front-end rejected for “Missing/Invalid NDC” when they shouldn’t.

This issue impacts claims received between July 1-Aug. 26, 2025, that had invalid HCPCS + NDC combinations on the claim that were valid on the date of service.

There’s nothing you need to do. We started working to reprocess these claims on Aug. 29, 2025.We value your partnership and the care you provide our members, and we sincerely apologize for any inconvenience this has caused. Thank you for your patience and understanding.

Annual Risk Adjustment Audits are Underway
Our Risk Adjustment team is reaching out to select provider offices via fax to request medical records for a Risk Adjustment Data Validation (RADV) audit and an Initial Validation Audit (IVA) for Medicare and commercial ACA members.

These audits are required by the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) and work to confirm the accuracy of the diagnoses we submit to CMS for our members for risk adjustment purposes.

What do you need to do?
If you’re contacted, please submit the requested documentation by the deadline provided in your communication.

We've Improved Our Medical Benefit Drug List
We’ve updated the format of our Medical Benefit Drug List (MBDL) to improve navigation and help providers more easily identify important information like medication coverage tier and prior authorization criteria.

What’s changing?
The MBDL is now separated by line of business into three new Medical Drug Lists (MDLs).

• Employer Group and MyPriority MDL
• Medicare MDL
• Medicaid MDL

You can find the new MDLs and our pharmacy Approved Drug Lists (ADLs) on our Drug Information page in the Provider Manual. To help with the transition, the MBDL will remain on the Provider Manual through September 30, while providers familiarize themselves with the MDL format.

Better functionality and added features
With the new MDLs, you can search for specific medications by drug name, reimbursement code or National Drug Code (NDC), and find links to prior authorization criteria, authorization forms and other reference documents, all in one place.

We want your feedback
As we work to improve the user experience of our medical and pharmacy drugs lists, we want to hear from you. Send your feedback, comments or questions to: ph-pharmacybusinessopswebsite@priorityhealth.com.