Medicaid participation

If you are not currently contracted with the Priority Health Medicaid product, Priority Health will reimburse you at the Michigan Medicaid fee schedule for covered services. Prior authorization may be required. Visit our authorizations page for instructions on how to request in-network and out of network authorizations. You may not balance-bill the member.

Go to the Michigan Medicaid fee schedule on the State of Michigan website.

New vs. established patients:

See the Medicare Claims Processing Manual,

Medicaid claim requirements

Medicaid is always the payer of last resort. When a Medicaid member is also covered by another payer, the Michigan Department of Health and Human Services (MDHHS) requires other payers be:

• Billed first
• Identified properly on the claim (see details below)

How to ensure your claims get paid

1. Ensure that ALL applicable Other Insurances are listed on the claim. You can find this information in CHAMPS.
2. Ensure that all required data elements are present for each Other Insurance listed on the claim.

Below in bold are the required data elements by loop. Elements identified with an * are situational and only required in certain circumstances.

Loop ID - 2320 - Other Subscriber Information

• SBR - Other Subscriber Information*
• CAS - Claim Level Adjustments*
• AMT - Coordination of Benefits (COB) Payer Paid Amount*
• AMT - Remaining Patient Liability*
• AMT - Coordination of Benefits (COB) Total Non-Covered Amount*
• OI - Other Insurance Coverage Information
  Claim Filing Indicator Code
  Yes/No Condition or Response Code
  Release of Information Code
• MIA - Inpatient Adjudication Information*
• MOA - Outpatient Adjudication Information*

Loop ID - 2330A - Other Subscriber Name

• NM1 - Other Subscriber Name
• N3 - Other Subscriber Address*
• N4 - Other Subscriber City, State, ZIP Code
• REF - Other Subscriber Secondary Identification*

Loop ID - 2330B - Other Payer Name

• NM1 - Other Payer Name
  Entity Identifier Code
  Entity Type Qualifier
  Name Last or Organization Name
  Identification Code Qualifier
  Identification Code
• N3 - Other Payer Address*
• N4 - Other Payer City, State, ZIP Code
• DTP - Claim Check or Remittance Date*
• REF - Other Payer Secondary Identifier*
• REF - Other Payer Prior Authorization Number*
• REF - Other Payer Referral Number*
• REF - Other Payer Claim Adjustment Indicator*
• REF - Other Payer Claim Control Number*

There may be certain circumstances where Other Insurance may not be applicable but should still be listed. We're constantly reviewing our procedures and code lists and conferring with MDHHS about discrepancies. However, we must still require providers to list Other Insurance in these circumstances until further notice.

Medicaid edit 21007

In January 2021, MDHHS implemented Medicaid edit 21007 which rejects claims that don't meet the criteria listed above.

In November 2021, we instituted our own edit 21007 to front-end reject these claims as well. If the edit identifies another payer based on a membership list provided by the State, and that payer isn't identified on the claim with all the information the state needs, it rejects the claim with the following message:

"Beneficiary Has Other Insurance so providers Must Submit Other Insurance Payer Information on the Encounter"

If your claim is rejected due to edit 21007, follow the steps in How to ensure your claims get paid above before resubmitting a corrected claim.

Medicaid edit 5169

Make sure the "Primary Specialty" field in your CHAMPS enrollment form is complete and an approved provider type. Pay close attention to the provider types you enter into the Attending, Referring and Ordering fields for Medicaid claims. Medicaid edit 5169 rejects claims for "non-approved provider types." Below are the allowed provider types per Medicaid policy:

Medicaid 180-day rule

As of Jan. 7, 2019, the 180 day rule, which allowed providers to resubmit claims subject to third party liability (TPL) investigation, is no longer in effect. When you submit a Medicaid claim that requires TPL review, the claim will be pended, reviewed and paid if no other liable parties are identified. Claims will continue to deny if our review determines there's another primary payer, including motor vehicle, worker's compensation or school-related injuries.

Medicaid short stays

Effective Jan. 1, 2018, the Michigan Department of Health and Human Services (MDHHS) established a Short Hospital Stay reimbursement rate of $1,608 for certain outpatient and inpatient hospital stays.

The qualification criteria, as outlined by MDHHS, are listed below. If a stay doesn’t qualify for the Short Hospital Stay rate, we’ll reimburse it at the normal Medicaid rate. 

Medicaid claims for select home health care services should be submitted through HHAeXchange

The Centers for Medicare & Medicaid Services (CMS) will soon require states use an Electronic Visit Verification (EVV) system to validate claim submissions for select home health care services covered under Medicaid. The State of Michigan has selected the vendor HHAeXchange to manage these claims. Beginning September 3, providers are encouraged to submit claims for the following codes/services to HHAeXchange:

• G0151: Services performed by a qualified physical therapist in the home health or hospice setting
• G0152: Services performed by a qualified occupational therapist in the home health or hospice setting
• G0153: Services performed by a qualified speech-language pathologist in the home health or hospice setting
• G0156: Services of home health/hospice aide in home health or hospice settings
• G0299: Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting
• G0300: Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting

The EVV effective date, at which time claims will only be accepted if submitted directly to HHAeXchange, hasn’t been determined by the state of Michigan. Learn more here. 

Medicaid fee schedules vs Priority Health policy

Priority Health is a Medicaid Health Plan (MHP).

Per the Medicaid Provider Manual, MHPs must consistently comply with and apply all applicable published Medicaid coverage guidelines and limitation policies for claims processing. MHPs have the option to provide benefits for services over and above the defined criteria within the Medicaid Provider Manual and MDHHS. The Medicaid fee schedule is one of the factors utilized to determine if CPT and HCPCS codes are payable services.

• If the CPT or HCPCS code isn’t on the Medicaid fee schedule, this service isn’t a payable service unless detailed within the Priority Health provider manual.
• If the CPT or HCPCS code is listed within the Medicaid fee schedule, these services are payable if any medical criteria defined for these services is met.

A CPT or HCPCS code being listed in the Medicaid fee schedule doesn’t automatically deem the service payable. MHPs can govern medical criteria for coverage of services through utilization management activities. This means that MHPs can define prior authorization requirements, utilization management and review criteria that determine if service is payable for CPT and HCPCS codes on the Medicaid fee schedule.

Priority Health defines these criteria in our medical policies and/or payment policy details throughout this Provider Manual.

Appealing claim denials by indicating the CPT or HCPCS is on the Medicaid fee schedule is insufficient to overturn appeals. As noted above, coverage criteria may exist that affects the claim processing as a payable service.