a message inside this issue from provider communicationsvestibular rehabilitation icd diagnosis...

Working Together For Quality Health Care

www.amerihealth.com

December 2006

INSIDE THIS ISSUENPI ANNOUNCEMENT• National Provider Identifier (NPI): Will You Be Ready?

ANNOUNCEMENTS• New Fee Schedule Inquiry Tool Accessible Through the NaviNetSM

Provider Portal• Health Care Plans for Medicare Beneficiaries: New Benefits in 2007

(PA Only)• Custom Chiropractic Benefit for One New Jersey Group

(PA/NJ Only)• Statement of Remittance (SOR) Enhancements• PCP and Pediatric Reimbursement Adjustment News (NJ/DE Only)

bIllINg• Updated Billing Information Regarding Vestibular

Rehabilitation Therapy

PhArMACy ANNOUNCEMENTS• FutureScripts™ Secure: The Pharmacy Benefits Management

Company for Medicare• Introducing “No Pay Copay”• Prescription Drug Updates• Select Drug Program® Formulary Updates

NAvINETSM NEwS• Referral Inquiries Through NaviNetSM

fOr yOUr PATIENT’S hEAlTh• CorCell® Offers Education and Cord Blood Banking Services• Updated Clinical Practice Guidelines Now Available• AmeriHealth Healthy LifestylesSM Provider Support Tools for

Member Education• Crohn’s Disease Added to ConnectionsSM AccordantCare™ Program

rEMINdErS• Transition to All-Electronic Authorization Inquiry and Submission• Provider Supply Line: For Office Supplies and Resources

Download and print...Additional copies of Partners In Health Update, can be printed by going to our website www.amerihealth.com/providers.

A Message from Provider CommunicationsThank you for reading Partners in Health Update. In this issue, we have dedicated a section to National Provider Identifier (NPI) announcements. Please see this section for additional information on obtaining and using your NPI.

we wanted to remind you to please send us any feedback or comments regarding the content and layout design. Our goal is to create a publication to best serve our provider network. To do that effectively, we would like your input.

Please send all comments and ideas on ways we can better communicate, to us at providercommunications@ amerihealth.com.

http://www.amerihealth.com/providers

Get It. The May 23, 2007 compliance date for the NPI is only 6 months away. We will require participating providers to use their NPI(s) in all electronic and paper health care transactions by the compliance date. Get your NPI(s) now so you have time to prepare. To learn more on how to apply, see How to Obtain an NPI or visit www.amerihealth.com/providers/npi.

Have your NPI and don’t know what to do with it? Share it. Share your NPI(s) with us and the colleagues who rely on them to submit claims (e.g., those who bill for, order, or refer services). We are asking you to report your NPI(s) to us beforethe May 23, 2007 compliance date so we can record them and test our systems to avoid a disruption when processing your claims. You should also share your NPI(s) with your billing service, vendor, or clearinghouse. To learn more on how to share your NPI(s) with us, contact your Network Coordinator or visit www.amerihealth.com/providers/npi.

Wewill notify you when you may begin submitting electronic and paper transactions with your NPI(s) prior to the compliance date. Until then, please continue submitting all electronic and paper transactions with your current provider identification numbers. If you have obtained your NPI(s) and shared them with us, you may begin to report them inadditiontoyourcurrentprovideridentificationnumbers. Remember, it is important to test your NPI(s) beforeMay 23, 2007 to avoid a disruption in claims processing.

The National Plan and Provider Enumeration System (NPPES) is currently accepting applications for NPIs. Providers who have not yet obtained an NPI may apply for it in one of the following ways:

Electronicu Complete the web-based application online

at https://nppes.cms.hhs.gov. This process takes approximately 20 minutes to complete and is the most time-efficient method of obtaining an NPI.

Paperu Providers may wish to obtain a copy of the paper

NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator. The form will be available only upon request through the NPI Enumerator. Providers who wish to obtain a copy of this form must contact the NPI Enumerator in any of the following ways:

uPhone: (800) 465-3203 or TTY (800) 692-2326

u E-mail:[email protected]

u Mail: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059

Share It.

Use It.

Getting an NPI is free –Not having one can be costly.

npi annOUnCEMEnT

� UPDATEPartners IN HealtH

December 2006 www.amerihealth.com

National Provider Identifier (NPI): Will You Be Ready?

How to Obtain an NPI

www.amerihealth.comUPDATEPartners IN HealtH

annOUnCEMEnTs

�December 2006

AmeriHealth 65® members received their Annual Notice of Change (ANOC) packet, addressing plan benefits and premium changes that are effectiveJanuary1,2007 through December 31, 2007.

Some group administrators may have elected changes in coverage for group members in 2007. If this is the case, these members will be advised of any changes by December 1, 2006.

Note: If employer group members have coverage through their former employer, Health and Welfare Fund, or association group, policy and procedures may differ. In some cases, benefits may vary. Group members should consult their benefits administrator or the Member Services Department for their individual plans.

health Care Plans for Medicare beneficiaries: New benefits in 2007 (PA Only)

What is AmeriHealth 65 Basic?ameriHealth 65 Basic is a special needs plan for those beneficiaries who are considered “full benefit dual eligibles.” in plain language, these members qualify for both Medicaid and Medicare.

With the arrival of Medicare’s part D pre-scription drug program, which was effective January 1, 2006, dual eligible beneficiaries now receive prescription drug coverage through Medicare, rather than Medicaid.

Medicare cost-sharing should be forwarded to Medicaid for consideration of payment. also, please be aware that these members cannot be balance billed.

BeginningDecember15,2006, we’re making our fee schedule rates available to all participating professional providers, via a new Fee Schedule Inquiry Tool accessible through the NaviNetSM portal. The fee schedule allowed amounts will reflect the provider’s specific contract rates for his or her written contractual agreement with AmeriHealth.

This information will provide physicians with online access to information about allowed amounts for contractual procedures prior to claim and benefit adjudication, and therefore does not provide the actual payment a provider may receive for a specific

submitted claim. The Fee Schedule Inquiry Tool does not include rates for capitated services or special contracting agreements. In addition, facilities and ancillary providers, and their fee schedule rates, are not accessible through this tool.

All professional provider offices that have access to the NaviNet portal will have access to the Fee Schedule Inquiry Tool through our Plan Central screens. Online instructions for use of the new transaction will be available through NaviNet.

New fee Schedule Inquiry Tool Accessible Through the NaviNetSM Provider Portal

annOUnCEMEnTs


� December 2006

Statement of remittance (SOr) EnhancementsWe are pleased to inform you that we are improving the paper Statement of Remittance (SOR) and making it more user-friendly. We listened to your feedback and based the improvements on your suggestions — especially for adjusted claims, claims retraction, and credit balances. Some of these revisions will impact the Electronic Remittance Advice (ERA).

Our first enhancement to the SOR, which we will implement by February, will link adjusted claims. When a claim is reversed and repaid, the adjusted claim number will appear on the statement below

the claim number originally used to pay the claim. The adjusted claim number will also appear in the ERA.

The ERA will show the original claim number in the REF 01 segment and the adjusted claim number in the REF 02 segment within the 2100 Loop.

We will make additional changes to the SOR at a later date.

Please share this information with your billing staff and your software vendor. If you have any questions, please contact your Network Coordinator or Provider Services.

Chiropractors in southern New Jersey and Pennsylvania please take note: Gloucester Township Public Schools is an employer group in southern New Jersey whose in-network chiropractic office visits do not require a referral.

This group offers both $5 copay and $10 PCP copay Public Sector Point-of-Service plans. Only the $5

PCP copay plans do not require a referral for in-network chiropractic visits.

If a member from this group who has a $5 PCP copay requests services, please be aware that no referral is required. Please call the Provider Services department with questions.

Custom Chiropractic benefit for One New Jersey group (PA/NJ Only)

PCP and Pediatric reimbursement Adjustment News (NJ/dE Only)Effective for dates of service from January 1, 2007, we will increase compensation for primary care physicians by paying certain primary care services on a fee-for-service basis that are currently included in capitation.

We continuously review our primary care reimbursement structure and we are committed to making adjustments as necessary to ensure you are properly compensated. We intend this adjustment to be another step in the right direction. The upcoming changes are as follows.

CapitationexceptionsforservicesprovidedtoHMOmembersThe administration of immunizations will no longer be considered capitated services. These services will be paid on a fee-for-service basis. The procedure codes impacted are:

• 90465 through 90474• G0008 through G0010

VaccineReimbursementforservicesprovidedtoHMOandPPOmembersVaccine reimbursement will increase to acquisition cost plus seven dollars ($7).

If you have any questions, please contact your Network Coordinator.


�December 2006

Billing

Updated billing Information regarding vestibular rehabilitation TherapyWe have updated our systems to accept HCPCS S9476 for billing vestibular rehabilitation therapy services. Vestibular rehabilitation therapy is considered medically necessary for any of the following conditions:

• Benign paroxysmal vertigo (BPPV)

• Chronic vestibular neuronitis or labyrinthitis

• Other labyrinthine disorders

• Acoustic neuroma (following surgery as the initial treatment of choice)

• Ototoxicity that results in vestibular dysfunction

• Disequilibrium of aging (a degeneration of balance capabilities due to age-related decline in function of the vestibular, proprioceptive, and visual senses)

• Surgical or chemical ablation of the vestibular system

• Meniere’s syndrome, during quiescent periods, when provocative movements or body positions exacerbate symptoms without postural control abnormalities

• Brain injury, including stroke that results in vestibular dysfunction

Vestibular rehabilitation is not included in the physical therapy capitation program. When billed with the appropriated diagnosis code vestibular rehabilitation therapy is eligible for a fee-for-service reimbursement. A valid referral is required. Please see the list of diagnosis codes eligible for a fee-for-service reimbursement.

VestibularRehabilitationICDDiagnosisCodeseligiblefee-for-servicereimbursement

Code Description225.1 Neuroma, acoustic (nerve) 386.00 Unspecified Meniere’s disease 386.01 Active Meniere’s disease, cochleovestibular386.02 Active Meniere’s disease, cochlear386.03 Active Meniere’s disease, vestibular386.04 Inactive Meniere’s disease386.10 Unspecified peripheral vertigo386.11 Benign paroxysmal positional vertigo386.12 Vestibular neuronitis386.19 Other and unspecified peripheral vertigo386.2 Vertigo of central origin386.30 Unspecified labyrinthitis386.50 Unspecified labyrinthine dysfunction386.51 Hyperactive labyrinth, unilateral386.52 Hyperactive labyrinth, bilateral386.53 Hypoactive labyrinth, unilateral386.54 Hypoactive labyrinth, bilateral386.55 Loss of labyrinthine reactivity, unilateral386.56 Loss of labyrinthine reactivity, bilateral386.58 Other forms and combinations of

labyrinthine dysfunction386.8 Other disorders of labyrinth386.9 Unspecified vertiginous syndromes and

labyrinthine disorders 780.4 Dizziness and giddiness 436 Acute, but ill-defined, cerebrovascular

disease If you have any questions regarding vestibular rehabilitation, please contact Provider Services.


� December 2006

In the July issue of Partners in Health Update, we announced the launch of a new pharmacy benefits management (PBM) company, FutureScripts, for our commercial members effective October 1, 2006.

EffectiveJanuary1,2007, we will implement a distinct version of this new PBM for our Medicare Part D beneficiaries — FutureScriptsTM Secure.

FutureScripts Secure will focus on managing the administration of Medicare Part D prescription drug benefits programs. FutureScripts Secure will establish

its own network of pharmacies, negotiate pricing directly with drug manufacturers, and develop its own rate for generic drugs to maximize cost savings for members. Caremark® will continue to provide mail order services.

futureScripts™ Secure: The Pharmacy benefits Management Company for Medicare

pHarMaCy annOUnCEMEnTs

To encourage the prescribing of generic drugs for our members, we will waive copayments and coinsurance for generic drugs purchased during the first quarter of 2007. We are calling this promotion, “No Pay Copay.” Please note that members with Medicare prescription drug coverage are not eligible for the “No Pay Copay” promotion. It is our goal to encourage our members to switch from brand drugs to equally effective and less costly generics. “No Pay Copay” begins on January 1, 2007 and ends on March 31, 2007.

Copayments and coinsurance for prescriptions processed and filled by the pharmacy during that

period will be waived. For example, if a prescription is dropped off on December 31, 2006, processed that same day, and held for pick up, the prescription is not eligible for “No Pay Copay,” even if the prescription is picked up on or after January 1.

We encourage you to discuss the benefits of generic drug alternatives and to prescribe generic drugs to your patients, where appropriate, to help them save money.

If you have any questions regarding this new program, please contact Pharmacy Services or your Network Coordinator.

Introducing “No Pay Copay”


�December 2006


For members enrolled in an AmeriHealth prescription drug program, there will be additional drugs that will require either Prior Authorization or Quantity Limits. The Prior Authorization requirements and Quantity Limits for the following drugs were made effective at the time the drugs became available.

DrugsRequiringPriorAuthorization

BrandDrug GenericDrug

Cesamet® Not Available

Daytrana® Not Available

Exjade® Not Available

Exubera® Not Available

Fentora® Not Available

Januvia® Not Available

Opana® Not Available

Ranexa® Not Available

Sprycel® Not Available

Zolinza™ Not Available

DrugwithQuantityLimit

BrandDrug GenericDrug QuantityLimit

Emend® 40mg Capsules

Not Available2 Capsules per 30 days

The purpose of these changes is to make certain that these drugs are being used appropriately and to guard against drug overuse.

Prescription drug Updates


� December 2006


Select drug Program® formulary Updates

The Select Drug Program® Formulary is a list of FDA-approved medications that were chosen for their effectiveness and value. The list changes periodically as the Pharmacy and Therapeutic Committee reviews the formulary to ensure its continued effectiveness. Below is a list of the most recent changes.

GenericAdditionsThese Generic Drugs recently became available in the marketplace. When these generic drugs became

available we began covering them at the appropriate Generic Formulary copayment:

GenericDrug BrandDrug FormularyChapter

azithromycin Zithromax® Susp 1. Antibiotics

clopidogrel bisulfate Plavix® 4. Heart, Blood Pressure, & Cholesterol

colestipol hcl Colestid® 4. Heart, Blood Pressure, & Cholesterol

diltiazem ER 24-hour Tiazac® 4. Heart, Blood Pressure, & Cholesterol

fentanyl citrate OTFC Actiq® 3. Pain, Nervous System, and Psych

finasteride Proscar® 14.Urinary and Prostate Meds

levonorgestrel/ethinyl estradiol

Seasonale® 11.Female, Hormone Replacement, Birth Control

meloxicam Mobic® 10. Bones, Joints, and Muscles

metronidazole lotion Metrolotion® 11. Female, Hormone Replacement, Birth Control

pilocarpine hydrochloride 7.5mg

Salagen® 7.5mg 16. Diagnostic & Miscellaneous Agents

potassium citrate 5mEq, 10mEq Urocit-K® 14. Urinary and Prostate Meds

sertraline Zoloft® 3. Pain, Nervous System, and Psych

tranylcypromine sulfate

Parnate® 3. Pain, Nervous System, and Psych

venlafaxine Effexor® 3. Pain, Nervous System, and Psych


�December 2006

Select drug Program® formulary Updates (continued)

BrandAdditionsThese Brand Drugs are covered at the appropriate Brand Formulary copayment:

BrandDrug FormularyChapter Effective

Actoplus Met® 7. Diabetes, Thyroid, Steroids, and Other Miscellaneous Hormones

May 11, 2006

Atripla® 1. Antibiotics and Other Drugs Used for Infection September 14, 2006

Avandaryl® 7. Diabetes, Thyroid, Steroids, and Other Miscellaneous Hormones

September 14, 2006

Wellbutrin XL® 3. Pain, Nervous System, and Psych September 14, 2006

Once a brand drug becomes available in the marketplace, and is approved by the Pharmacy and Therapeutics Committee as a formulary drug, will be added to the formulary and available at the brand formulary copayment.

BrandDeletionsThese Brand Drugs are covered at the appropriate Non-Formulary copayment:

Effective January 1, 2007

BrandDrug GenericDrug

Actiq® fentanyl citrate OTFC

Colestid® colestipol hcl

Effexor® venlafaxine

Metrolotion® metronidazole lotion

Parnate® tranylcypromine sulfate

Plavix® clopidogrel bisulfate

Proscar® finasteride

Salagen® 7.5mg pilocarpine hydrochloride 7.5mg

Seasonale® levonorgestrel/ethinyl estradiol

Tiazac® diltiazem ER 24-hour

Urocit-K® potassium citrate 5mEq, 10mEq

Zithromax® Susp azithromycin

Zoloft® sertraline

The generic drugs for all of these brand drugs are on the formulary and are available at the generic formulary copayment.



10 December 2006

navinETsM nEWs

Your office can easily review referral information via NaviNetSM Plan Central. You can look at all referrals from your office during the previous two weeks, or you can enter a specific member ID and see a list of all referrals for that member during the previous 12 months.

MultipleMemberReferralInquiryThe Multiple Member Referral Inquirywill display all referrals issued to your practice within the last two weeks. Choose Authorization and Referral Inquiry from the drop-down under Plan Transactions, and then select Referral Inquiry. Select your office from the drop-down field Referred From/To, then click on the Search button. You may leave the default date range as displayed. You can view the detail of each referral by clicking on the Select button.

If too many results are returned, you can shorten the date range.

SingleMemberReferralInquiryIf you prefer, you can search for a specific member’s referral by typing the member’s last name/first name, member ID number, or referral number. When narrowing your search to a specific member referral, you have the option of modifying the Referral Date From field for up to one full year.

Note: Some referral details may change slightly once the referral has processed. Referrals not submitted electronically require as many as five business days to be updated.

referral Inquiries Through NaviNetSM


11December 2006

fOr yOUr paTiEnT’s HEalTH

CorCell® Offers Education and Cord blood banking ServicesDiscounted fees for umbilical cord blood preservation have been offered to our members since 1997 through the CorCell® Saving Baby’s Cord Blood® Program. Thousands of our members have received a discount for cord blood collection and preservation with CorCell, a national private umbilical cord blood (UCB) bank based in Philadelphia, as part of our value-added wellness programs.

Today, umbilical cord blood stem cells may be used to treat over 70 diseases, including leukemia, bone marrow disorders, aplastic anemia, Hodgkin’s disease, non-Hodgkin’s lymphoma, genetic disorders and tumors of the plasma cells, nerve cells, and the retina. Medical researchers are also exploring new uses for these stem cells in treatments for conditions such as Alzheimer’s, Parkinson’s, heart attack, diabetes, stroke, and spinal cord injury.

In your office, in print, and on the web, CorCell can provide you and your patients with information about cord blood stem cell preservation and medical therapies.

CorCelloffers:• Reimbursement up to $100 for provider services

rendered for cord blood collection.

• Patient education materials and 365-days-a-year, and 24-hours-a-day/7-days-a-week customer service support.

• Assurance of pure and safe handling of a newborn’s cord blood with PurePath™

processing.

• Continuing education program credits for physicians, nurse practitioners, and nurses.

• $350 discount for our members for cord blood collection.*

For more information contact CorCell at (888) 326-7235 or visit www.corcell.com.

Look for more information about CorCell in the next issue.* This is not a covered benefit.

Note: An AmeriHealth affiliate has a minority ownership interest in CorCell, Inc.’s parent company.

We have recently updated the Clinical Practice Guidelines grid which now includes the adoption of the U.S. Preventive Services Task Force Preventive Health Guidelines. These guidelines will replace the 2005 Preventive Health Guidelines. The ultimate goal is to provide evidence-based clinical practice information that is consistent with nationally recognized standards of care.

Clinical Practice Guidelines represent an accepted minimum standard of care in the medical profession. Individual clinical decisions should be tailored to the patient’s specific medical and psychosocial needs.

Clinical Practice Guidelines are not a statement of benefits. All benefits will need to be verified with the member’s plan. Although these guidelines are adapted from national sources, information in these areas may evolve rapidly and can lead to changes in recommendations. As changes occur, please update your practice accordingly.

Copies of this guideline and any of our plan-adopted guidelines can be obtained by contacting our Provider Supply Line at (800) 858-4728, or by downloading them at www.amerihealth.com/providers.

Updated Clinical Practice guidelines Now Available


1� December 2006

Enclosed you will find a summary of AmeriHealth Healthy LifestylesSM Provider Support Tools for Member Education. These tools will assist you in educating your patients, our members, about the preventive health initiatives that are available through the AmeriHealth HealthyLifestyles Program.

The purpose is to educate members on the added value-added programs available to them.

The AmeriHealth Healthy Lifestyles Provider Support Tools for Member Education summary is located on our website at www.amerihealth.com/providers or by calling the Provider Supply Line.

Amerihealth healthy lifestylesSM Provider Support Tools for Member Education

In a continuing effort to support our members with chronic conditions, Crohn’s Disease will be added to the list of complex chronic diseases managed through the ConnectionsSM AccordantCare™ Program, effectiveDecember1,2006. The Connections AccordantCare Program is offered in partnership with Accordant Health Services (Accordant), a Caremark® company.

Similar to other conditions that are part of the Connections AccordantCare Program, Crohn’s Disease is complex, affects a significant segment of the membership, and has complications that may be avoidable. With the addition of Crohn’s Disease, the Connections AccordantCare Program will continue to focus on educating members about their disease, including the importance of reporting symptoms to their doctor and adherence to providers’ treatment plans.

The Connections AccordantCare Program is available to members with any of the following 16 diseases:

• Seizure Disorders• Rheumatoid Arthritis• Multiple Sclerosis • Crohn’s Disease• Parkinson’s Disease• Systemic Lupus Erythematosus (SLE)• Myasthenia Gravis• Sickle Cell Disease• Cystic Fibrosis• Hemophilia• Scleroderma• Polymyositis• Chronic Inflammatory Demyelinating

Polyradiculoneuropathy (CIDP)• Amyotrophic Lateral Sclerosis (ALS)• Dermatomyositis• Gaucher Disease

For more information about the program, visit www.accordant.com or call (866) 398-8761.

Crohn’s disease Added to ConnectionsSM AccordantCare™ Program

fOr yOUr paTiEnT’s HEalTH


1�December 2006

Provider Supply line: for Office Supplies and resourcesTo replenish office supplies such as a Provider Manual, forms, and Clinical Practice Guidelines, please call the toll-free Provider Supply Line at (800) 858-4728.

Please have the following information ready so your order may be processed in an error-free, timely manner:

• Provider identification number• Office name• Office address• Office telephone number

If any information is missing, your order may not be processed. A properly submitted order may take three to five business days to arrive at your office. If you are unsure of your provider identification number, contact Provider Services or your Network Coordinator.

Please note:Calls to the Provider Supply Line should be for supply requests only. All other provider inquiries should be directed to Provider Services. Orders placed through Provider Services willnotbe accepted.

rEMinDErs

Transition to All-Electronic Authorization Inquiry and SubmissionTo maintain accuracy and speed of processing for the millions of transactions we complete yearly, we will be transitioning to an all-electronic format for authorization inquiry and authorization submission, with the exception of behavioral health authorizations, which are still authorized by Magellan Behavioral Health, Inc.

Our electronic authorizations initiative is divided into two phases; the first phase is the NaviNetSM portal. The second phase includes the addition of two enhancements to the provider Interactive Voice Response (IVR) system — Authorization Status Inquiry and Authorization Submission.

As of October 2, 2006, providers are now able to access the status of their authorizations via the first enhancement to the IVR. Prior to implementation of this enhancement, we conducted a pilot phase of the IVR’s Authorization Status Inquiry, allowing 21 providers access to authorization status in exchange for their feedback. The feedback was positive, with most providers calling the enhancement an efficient method for obtaining authorization

status. We encourage you to call the IVR directly to access Authorization Status Inquiry by saying “Authorization” or choosing option 7 on the main menu.

We are currently developing the second enhancement — Authorization Submission. Look for more details regarding our electronic authorizations initiative in upcoming editions of Partners in Health Update.

To get connected to the navinetsM portal, please call the eBusiness provider Hotline at (856) 638-2701 (nJ), (302) 661-6111 (DE), or (215) 640-7410 (pa) or complete our Online inquiry form at www.amerihealth.com/providers/navinet.

Please note: Minimum requirements must be met to obtain access to the navinetsM portal. please contact the eBusiness provider Hotline to determine eligibility.

View our online provider directories at www.amerihealth.com

AmeriHealth products are offered directly by QCC Insurance Company d/b/a AmeriHealth Insurance Company, AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey.

This is not a statement of benefits. Benefits may vary based on state requirements, product line (HMO, PPO, Indemnity, etc.), and/or employer groups. Providers should call Provider Services, listed at right, for the member’s applicable benefit information. Members should be instructed to call the number on the back of their identification card.

Not all benefit plans use Magellan Behavioral Health, Inc. to administer behavioral health benefits. Please check the back of the member’s ID card for the telephone number to contact for behavioral health services, if applicable.

The third-party Web sites mentioned in this publication are maintained by organizations over which AmeriHealth exercises no control, and accordingly, AmeriHealth disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefit plans. Members should refer to their benefit contract for complete details of the terms, limitations, and exclusions of their coverage.

Current Procedural Terminology (CPT®) is a copyright of the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

Investors in NaviMedix®, Inc. include an affiliate of AmeriHealth, which has a minority ownership interest in NaviMedix®, Inc.

12/06

iMpOrTanT rEsOUrCEs

The AmeriHealth Partners in Health monthly Update is a publication of the Provider Communications department for the exchange of information and ideas among the AmeriHealth Provider community. Suggestions are welcome.

CONTACT INFORMATION:

Caroline CrispinoManaging Editor

Charleen BaseliceProduction Coordinator

ProviderCommunicationsAmeriHealth1901MarketStreet35thFloorPhiladelphia,PA19103

providercommunications @amerihealth.com

CARE MANAGEMENT AND COORDINATION (800) 227-3116 (NJ, DE, PA)

Case Management (800) 313-8628 (NJ, DE, PA)

Baby FootSteps® (800) 598-BABY [2229]

CONNECTIONSSM HEALTH MANAGEMENT PROGRAMS Connections Health Management Program Provider Support Line (866) 866-4694

ConnectionsSM Kidney Program (866) 303-4CKP [4257]

ConnectionsSM AccordantCareTM Program (866) 398-8761

CORPORATE AND FINANCIAL INVESTIGATIONS DEPARTMENT Anti-Fraud and Corporate Compliance Hotline

(866) 282-2707www.amerihealth.com/anti-fraud

CREDENTIALING VIOLATION HOTLINE (215) 988-6534 www.amerihealth.com/credentials

eBUSINESS PROVIDER HOTLINE(856) 638-2701 (NJ)(302) 661-6111 (DE)(215) 640-7410 (PA)

HEALTH RESOURCE CENTER AmeriHealth Healthy LifestylesSM (800) 275-2583

Precertification (215) 241-2100(800) 227-3116

PHARMACy SERVICES Prescription Drug Authorization Toll Free Fax

(888) 678-7012(888) 671-5285

Direct Ship Injectable

Fax

(267) 402-1711(888) 678-7012

(215) 761-9165

Blood Glucose Meter Hotline (888) 494-8213 (option 2)

PROVIDER ELECTRONIC DATA INTERCHANGE SERVICES wEB PAGE www.amerihealth.com/edi

PROVIDER INFORMATION and TOOLS wEB PAGE www.amerihealth.com/providers

PROVIDER MEDICAL POLICy wEB PAGE www.amerihealth.com/medpolicy

PROVIDER PHARMACy wEB PAGE www.amerihealth.com/provider_rx

PROVIDER SERVICES (Policies/Procedures/Claims) HMO

(800) 821-9412 (NJ)(800) 888-8211 (DE)

PPO (800) 595-3627 (NJ)(800) 888-8211 (DE)

PROVIDER SUPPLy LINE (800) 858-4728

Visit our website at www.amerihealth.com

AmeriHealthHealthy LifestylesSM

Provider Tools for Member Education

Goal: Educate members on the value-added benefits available through the AmeriHealth Healthy LifestylesSM Programs, including incentives for lifestyle changes and reminder programs.

Program Content: • Educational information• Screening recommendations, tests and

immunization reminders• Incentives for lifestyle changes

Reimbursement Programs:• Fitness• Smoking Cessation• Healthy Weight, Healthy You• First Aid and Safety

Discounted Programs:• CorCell® Saving Baby’s Cord Blood®

• Stress Management and Better Sleep

Other Programs:• Adoption Education• Stress Management and Better Sleep• Men’s Health• Women’s Health

Members can view complete descriptions of all AmeriHealth Healthy

LifestylesSM Programs and eligibility

requirements at www.amerihealthexpress.com†

or www.amerihealth.com

AmeriHealth Healthy LifestylesSM

Goal: An interactive tool designed to help members develop ways to improve their personal health goals.

Lifestyle Questionnaire:After completing a fifteen-minute lifestyle questionnaire members:

• Receive a customized report identifying possible health risks• Receive recommendations for lifestyle improvements

• Learn how our AmeriHealth Healthy LifestylesSM Programs can help them achieve their personal health goals.

Profile Topics:• Nutrition • Stress and well-being• Check-ups• General health habits• Cardiovascular health

Completing a Personal Health Profile:• Members can complete a Personal Health Profile by

visiting our Web site or calling the Health Resource Center at 1-800-275-2583 for additional information

Members can complete a Personal Health Profile at www.amerihealth.com or

www.amerihealthexpress.com†

Personal Health Profile

Goal: Provide members and their families with information on various tools to achieve and maintain their ideal weight.

Self-directed Program Options:• Weight management for children 2-17 and adults 18 and older• One-on-one counseling with a Registered Dietician• Health Assessment ➢ Understanding overweight and obesity ➢ Body Mass Index (BMI) ➢ Personal Health Profile• Support Programs (1) Group Support ➢ Weight Watchers®

➢ In-network hospital weight management programs ➢ HIP Kids: A 12-week program offered to children

8 and older at selected YMCA locations (2) Individual Support ➢ Personal Health Coach ➢ Nutrition specialists ➢ Max’s Magical Delivery: Fit for Kids Free DVD (3) Informational Support ➢ Links to a list of health-related Web sites ➢ On-line member wellness tools• Incentives ➢Fitness reimbursement - up to $150 with 120 completed workouts within

365 days ➢ Nutrition counseling - up to 25% discount on services ➢ Weight Watchers® reimbursement - up to $200 towards cost of program ➢ Approved weight management programs - up to $200 towards cost of program

Healthy Weight, Healthy You

Weight Watchers® is a registered trademark of Weight Watchers International, Inc.

Members can view a complete description of

Healthy Weight, Healthy You at

www.amerihealthexpress.com††


Goal: A booklet outlining the nationally recommended schedule of wellness visits including preventive screening services.*

Guideline Content:• Personal Health Record• Lifetime immunization schedule helps members track

and discuss their health maintenance activities with their health care providers

• Age-specific recommended screenings

Member Wellness Guidelines*

Members can download Personal Health Record, Immunization Schedule, and Member Wellness

Guidelines at www.amerihealthexpress.com††


Goal: Helps identify and manage possible risk factors for mothers-to-be, such as pre-term delivery and other potential complications.

Perinatal High-Risk Maternity Program: • Telephonic outreach• Assessment• Education• Intervention• Case managers work with health care providers to educate and

support members throughout the pregnancy continuum

Additional information:• Members can call 1-800-598-BABY

Call 1-800-598-BABY to enroll your

maternity patients†

Goal: Provide parents of nine-month old children with current national immunization recommendations.u

Program Content:• Telephonic reminders • The Centers for Disease Control and Prevention’s

Recommended Childhood Immunization Schedule from birth to 12 years of ageu

• Answers to frequently asked questions and concerns about pediatric vaccinations

Provider Tool:• Print/download a copy to discuss with your patients.

Members can download a copy of the Lifetime Immunization

Schedule at www.amerihealthexpress.com†


Goal: Ensure that children receive all age-appropriate recommended immunizations.t

Program Content:• Mailing for parents of 18-month-old children. • Includes all age-appropriate recommended vaccinationsu

• Addresses parents’ questions and concerns about pediatric vaccinations

• Tool for parents to record the dates of their children’s immunizations

• Telephonic reminders

Provider Tool:• Print/download a copy to discuss with your patients

Members can view or download copies of the Pediatric Immunization

Schedule at www.amerihealthexpress.com†


Baby FootSteps®

Newborn Immunization Program

Pediatric Immunization Program

Adolescent Immunization ProgramGoal: Provide parents of 11–13 year old adolescents with a summary of the Centers for

Disease Control and Prevention’s Recommended Childhood Immunization Schedule from birth to 13 years of age.t

Program Content:• Annual mailing to parents; includes a list of nationally

recognized health education resources along with their Web sites, addresses, and telephone numbers

• Directs families and their children to our Web site for adolescents Gen-Y Health ClubSM

• Encourages adolescents to learn how to make healthy choices and become more physically active

• Revised Gen-Y Health Club site includes health information and games designed to hold the interests of adolescents and growing teens and encourages their return to the site

Provider Tool:• Print/download a copy to discuss with your patients

Members can obtain information on adolescent health topics by visiting

our newly designed Gen-Y site at

www.amerihealth.com/gen-y† or www.amerihealth.com

Flu and Pneumococcal Vaccination ProgramGoal: Provides members 65 years of age and older, as well as those identified as high risk,

with vaccination information regarding the importance of influenza and pneumonia prevention.

Program Content:• Mailed educational information• Answers to frequently asked questions about the

flu vaccine• Telephonic reminders

For national recommendations on

Flu and Pneumococcal Vaccination, members

can go to www.amerihealthexpress.com†


Goal: Ensure that all women 40 years of age and older receive an annual mammogram.

Program Content:• Annual birthday card reminder to all female managed

care members ≥40 to schedule annual mammograms • Updated recommendations for breast cancer screening

from the American Cancer Society • Reminder to schedule regular Pap tests by visiting the

College of American Pathologists’ (CAP) Web site.• Opportunity to register on the American Cancer

Society’s Web site at www.cancer.org to receive or send someone they care about, a free email reminder to schedule an annual mammography screening

Mammography Birthday Card Program

Members can receive additional information or

sign up to receive an e-mail reminder at



Cervical Cancer Screening Program

Goal: Promotes the importance of regular pelvic examinations and Pap tests among women ages 19 and older through annual educational reminders.

Program Content:• The American Cancer Society’s recommendations for

cervical cancer screening• Information regarding ➢ Human papilloma virus (HPV) ➢ Risk factors ➢ Preventive measures ➢ Other important health information • Opportunity to register with CAP, to receive a free email reminder to schedule an

annual Pap test at www.myhealthtestreminder.com

Members can receive additional information or sign up to receive an

e-mail reminder at www.amerihealthexpress.com†


Colorectal Cancer ScreeningGoal: Increase awareness of and compliance with colorectal cancer screening among male

and female members > 50.

Program Content:• Mailed outreach encouraging dialogue between members

and health care providers regarding the importance of colorectal screening

• Telephonic reminders• Opportunity to register with CAP, to receive a free email

reminder to schedule a colorectal cancer screening at www.myhealthtestreminder.com

For additional information, members can sign up to receive an e-mail

reminder at www.amerihealthexpress.com†


Goal: Increase members’ knowledge and awareness of osteoporosis prevention and screening.

Program Content:• Mailed educational information• Telephonic reminders• An Osteoporosis Risk Assessment Test and a Member

Safety Checklist available on our Web site for members to discuss with their health care providers

Osteoporosis Prevention and Screening

Members can assess their risk for osteoporosis by

completing a Risk Assessment Test at



ConnectionsSM Health Management Programs

Goal: Designed to assist providers and their patients to manage chronic conditions and to help patients make confident, informed decisions regarding certain medical conditions.

ConnectionSM Health Management Program:• Offers Disease Management services to patients with one

or more of the following conditions: ➢Asthma ➢Diabetes ➢Coronary Artery Disease (CAD) ➢Chronic Obstructive Pulmonary Disease (COPD) ➢Congestive Heart Failure (CHF)

Decision Support• Identifies and supports members facing a treatment option

decision, or need help with everyday health concerns

Personal Health Coaches• Registered Nurses, Dieticians, and Respiratory Therapists

specially trained to support patients 24/7• Provide Disease Management and Decision Support

services, and general information to help patients understand their diagnosis and symptoms

• Members receive personalized calls, mailed educational information and health reminders regarding chronic conditions and other health concerns

SMARTTM Registry• A distribution of comprehensive semi-annual clinical reports to local provider

networks who provide integrated care to patients with one or more of the chronic conditions

• Contains several reports with an “at-a-glance” summary of patient care • Follows evidence-based guidelines reported at the patient level• Allows for easy interpretation of clinical information at the point of care• Results in improved clinical quality and outcomes for patients• Improves provider satisfaction ratings

The Dialog Center• Messaging Center – members can request information from a Health Coach• Health Tools – Help members track their medications and symptoms• Healthwise

® Knowledgebase – an on-line encyclopedia of health topics, available in

English and Spanish• Health Crossroads

® Web site – provides members with up-to-date unbiased

information

ConnectionsSM Kidney Program:• Focuses on improving clinical outcomes, by managing co-morbid conditions and

preventing complications associated with end-state renal disease (ESRD)

ConnectionsSM AccordantCareTM Program:• Designed to improve patients’ compliance and self-management skills to support

treatment plans with 16 complex conditions (e.g. Multiple Sclerosis, Parkinson’s Disease, Sickle Cell Disease, and others)

Members can view complete descriptions of the ConnectionsSM Health Management

Program and all medical conditions listed under the Decision Support,

the ConnectionsSM Kidney and the ConnectionsSM

AccordantCareTM Programs at



AmeriHealthHealthy LifestylesSM

For complete program descriptions and eligibility requirements, members can call the Health Resource Center at 1-800-275-2583.t �Based�on�the�Centers�for�Disease�Control�and�Prevention’s�Recommended�Childhood�Immunization�Schedule—United�States,�2006,�approved�by�the�

Advisory�Committee�on�Immunization�Practices�(ACIP),�the�American�Academy�of�Pediatrics�(AAP),�and�the�American�Academy�of�Family�Physicians�(AAFP).

*��The�Wellness�Guideline�recommendations�have�been�adapted�from�the�U.S.�Preventive�Services�Task�Force�of�the�U.S.�Public�Health�Department�and�other�nationally�recognized�sources.�

†��Providers�can�view�complete�descriptions�of�all�programs�listed�in�this�brochure�by�visiting�our�Web�site�at�www.amerihealth.com.

Certain�restrictions�may�apply.�Connections�is�not�available�to�self-funded�groups�that�do�not�purchase�the�program.�Please�refer�to�your�benefit�description/contract�material�for�complete�details�of�the�terms,�limitations,�and�exclusions�of�your�health�care�coverage.�For�coverage�information�and�questions,�please�contact�Member�Services�at�the�number�printed�on�your�member�ID�card.

www.amerihealth.com

(2005-0144) 11/06 AH PROV

Work Site Wellness/Wellness Partners®

Goal: Develop on-going partnerships with large employer groups focused on bringing targeted health education, screenings and wellness programs directly to the work site.

Wellness Partner Employer Benefits:• Health education programs• Health screenings• Access to an extensive video tape lending library• Flu shots• Smoking cessation programs• Mobile mammography• Collaboration with our health education team to assess

and identify modifiable health risks of an employee population

Program Content:• Stress management• Prevention• Lifestyle change• Self-care• Nutrition • Disease management

For an overview of our Work site Wellness

programs, employers can go to

www.amerihealth.com†

AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • QCC Insurance Company, d/b/a AmeriHealth Insurance Company

GR A P HIC COMMUNICATIONS

I N T E R N AT I O N A L U N I O N

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