partners in health update - december 2013 -

December 2013www.amerihealth.com/providers

► Articles designated with an orange arrow include notice of changes or clarifications to administrative policies and procedures.

Inside this edition ADMINISTRATIVE

► Contraceptive coverage update for religious organizations ► New payment option for migrated AmeriHealth Pennsylvania members with spending accounts

● Verify member cost-sharing at the time of service ● Provider Automated System not available for migrated

AmeriHealth Pennsylvania members

BILLING ● Revised time line for new CMS-1500 (02/12)

claim form ► Enforcement of industry standards related to platform transition for AmeriHealth Pennsylvania members

► Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2014

► Medically Unlikely Edits now applied to professional and facility claims for AmeriHealth Pennsylvania members

MEDICAL ● Reminder: Updates to precertification requirements effective

January 1, 2014 ► Policy notifications posted as of November 25, 2013 ► Coverage for certain surgical procedures ► Coverage for injectable drugs that reduce the risk of preterm birth

► Changes to sleep study precertification requirements for Medicare Advantage HMO members

PHARMACY ► Select Drug Program® Formulary updates ► Prescription drug updates

ICD-10 ● Putting ICD-10 into Practice: Coding exercises and

scenarios

PRODUCTS ► AmeriHealth New Jersey products available both on and off the Health Insurance Marketplace

NAVINET®

► New NaviNet functionality for ePayment, Cap Rosters, and other transactions

QUALITY MANAGEMENT ● Standards for medical record documentation ● Our Quality Management Program promotes quality

of care and service ► Upcoming changes to the measures for the QPM score program — measurement year 2014 (NJ and DE only)

HEALTH AND WELLNESS ► Help your older adult patients understand the connections among depression, sleep, and exercise

Verify member cost-sharing at the time of service page 5

For articles specific to your area of interest, look for the appropriate icon:

Professional

Facility

Ancillary

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2013 www.dreamstime.com. All rights reserved.

This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.

The third-party websites 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 are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.

NaviNet® is a registered trademark of NaviNet, Inc.

CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of AmeriHealth HMO, Inc. and its affiliates (AmeriHealth) created to provide valuable information to the AmeriHealth-participating provider community. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with AmeriHealth. This publication is the primary method for communicating such general changes. Suggestions are welcome.

Contact Information:

Provider CommunicationsAmeriHealth1901 Market Street 27th FloorPhiladelphia, PA 19103

[email protected]

AmeriHealth HMO, Inc. and AmeriHealth 65® NJ HMO have an accreditation status of Commendable from the National Committee for Quality Assurance (NCQA).

AmeriHealth services help patients communicateFor your patients who have difficulty communicating because of an inability to speak or understand English, AmeriHealth provides language assistance services through the AT&T Language Line. Please instruct these patients to call Customer Service at 1-800-275-2583 for members in Pennsylvania and Delaware and 1-888-YOUR-AH1 (1-888-968-7241) for members in New Jersey and follow the prompts, or wait to speak to a Customer Service representative.

For the hearing-impaired, the telephone number is 1-888-857-4816.

December 2013 | Partners in Health UpdateSM 3 www.amerihealth.com/providers

AdministrAtive

Contraceptive coverage update for religious organizationsThe Affordable Care Act, also known as health care reform, requires non-grandfathered health plans to cover certain contraceptive services for women with no out-of-pocket costs (i.e., $0 cost-sharing). There are two exceptions to this requirement:

● Religious employer exemption. Religious employers can elect not to provide coverage and their employees are not eligible for coverage.

● Non-profit religious organization: Non-profit religious organizations can elect not to cover contraceptives for religious reasons but are not exempt as a “religious employer.”

For these non-profit religious organizations, the Affordable Care Act requires that AmeriHealth pay the cost of certain contraceptive services.

Eligible members within these organizations will receive a separate ID card that indicates “Contraceptive Coverage.” Using this ID card, contraceptive methods approved by the U.S. Food and Drug Administration will be covered at an in-network level with no cost-sharing under the medical benefit and covered with no cost-sharing for generic products and for those brand products for which we do not have a generic equivalent under the pharmacy benefit at retail and mail order pharmacies.*

It is important that only contraceptive services for these members be billed using the ID number on the Contraceptive Coverage ID card.* In addition, contraceptive services will not be covered when any other ID card is used.

AmeriHealth New Jersey Medical and Rx Contraceptive Coverage

Contraceptive coverage for AmeriHealth members in Pennsylvania is being offered through a non-AmeriHealth vendor. These members will receive information directly from the coverage provider.

Please contact your Network Coordinator if you have any questions about this coverage or billing.

*Contraceptive services are covered under the pharmacy benefit only if the member has an AmeriHealth prescription drug plan.

AmeriHealth NJWPHCS Sample ID Card

Medical with Rx

SAMPLEMEMBER

Rx BIN CONTRACEPTIVE COVERAGE600428Rx PCN 03820000

USI1234567800

Pharmacy Benefits Administrator

Visit www.amerihealthexpress.com for benefit information

Member: Use this card for eligible medical and/or prescription contraceptive services only.

Submit Paper Claims to: AmeriHealth Service CenterP.O. Box 41574 Philadelphia, PA 19101-1574

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Your insured benefits are underwritten byAmeriHealth Insurance Company of New JerseyAmeriHealth Service CenterP.O. Box 41574 Philadelphia, PA 19101-1574

Customer Service1-888-968-7241Pharmacy Benefits1-888-678-7012

AmeriHealth NJWPHCS Sample ID Card

Medical only

SAMPLEMEMBER

CONTRACEPTIVE COVERAGE

USI1234567800

Visit www.amerihealthexpress.com

Member: Use this card for eligible medical contraceptive services only.

Submit Paper Claims to: AmeriHealth Service CenterP.O. Box 41574 Philadelphia, PA 19101-1574

Paper claims submission required only when an in-network provider is not available for contraceptive services.

Your insured benefits are underwritten byAmeriHealth Insurance Company of New JerseyAmeriHealth Service CenterP.O. Box 41574 Philadelphia, PA 19101-1574

Customer Service1-888-968-7241

Medical Contraceptives Only — No AmeriHealth New Jersey Rx Coverage*

AmeriHealth New Jersey Contraceptive Coverage ID card

AmeriHealth Pennsylvania members Contraceptive Coverage ID card


AdministrAtive

New payment option for migrated AmeriHealth Pennsylvania members with spending accountsAs of January 1, 2014, AmeriHealth Pennsylvania members who have been migrated to the new operating platform and have spending accounts will have a new payment option called Direct Pay to Provider (DPTP). DPTP allows members to pay providers directly from their Health Savings Account (HSA), Health Reimbursement Account (HRA), or Flexible Spending Account (FSA). For HRA and FSA participants, DPTP is an employer-configuration option only; HSA participants can set up their preferences through our secure member website, amerihealthexpress.com.

Providers will be able to view HRA details through the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal, including the deductible amount and who is responsible for payment first (the employer or the member), and how much they would pay. Unless informed by the member, providers are unable to determine whether a member has an FSA or HSA.

For medical claims that require processing to determine the member liability, the claim is processed and then automatically sent to the spending account system to determine if the claim is covered and if funds are available under one or more spending accounts. If the account is an FSA or HRA and the employer offers DPTP, the payment is either automatically sent to the provider or sent after the member has approved it. In this case, the provider will receive a spending account Explanation of Payment (EOP). Providers will be able to view EOPs through the EOB and Remittance Inquiry transaction on NaviNet. A spending account payment related to a medical claim will generally arrive a week after the claim has been completely processed.

Provider and facility EOPsEOPs will differ depending upon the method of payment (check vs. electronic funds transfer [EFT]). The example below shows a sample provider EOP. A guide explaining how to read your EOP will be available in the Claims Submission and Payment section of our Upcoming System and Process Changes site at www.amerihealth.com/pnc/upcomingchanges in the coming weeks.

Spending Account Processing

Spending Account Processing1901 Market Street Philadelphia, PA 19103-1480

EXPLANATION OF PAYMENTPage of

IO000007

CHECK IS ENCLOSED

DR. IMA SAMPLEPO BOX 9999PHILADELPHIA, PA 19999-9999

1 4

AUGUST 14, 2013

PROVIDER SUMMARY

Provider: DR. IMA SAMPLE

Provider Number: 9999990000

PAYMENT SUMMARY

PROVIDER CHECK NUMBER ........................ 010000176

TOTAL SPENDING ACCOUNT FUNDS PAYABLE ......... $2,950.00

TOTAL PROVIDER PAYMENTS....................... $2,950.00

Spending Account Processing

Spending Account Processing1901 Market Street Philadelphia, PA 19103-1480

EXPLANATION OF PAYMENTPage of

IO000004

DEPOSIT NOTICE ONLY

DR. IMA SAMPLE PO BOX 999999PHILADELPHIA, PA 19999-9999

1 3

JUNE 14, 2013

PROVIDER SUMMARY

Provider: DR. IMA SAMPLE

Provider Number: 9999999000

DIRECT DEPOSIT SUMMARY

FUNDS AVAILABLE DATE 06/19/2013 EFT PAYMENT NUMBER 9999999999

ACCOUNT TYPE CHECKING

TOTAL SPENDING ACCOUNT FUNDS PAYABLE ......... $65.00

TOTAL SPENDING ACCOUNT EFT DEPOSIT ........... $65.00


AdministrAtive

Verify member cost-sharing at the time of serviceAmeriHealth offers a variety of products that hold members responsible for cost-sharing amounts (i.e., copayments, coinsurance, and deductibles) for covered services they receive. In addition, we have introduced several new products on the Health Insurance Marketplace (in New Jersey) and benefit changes that will go into effect on January 1, 2014. As a result, we would like to take this opportunity to remind you that cost-sharing varies based on the member’s type of coverage and benefit plan and can include applicable cost-sharing for both facility and professional services.

It is imperative that you ask members for their current health plan ID card and verify not only member eligibility but also cost-sharing amounts each time a member is seen (e.g., in the doctor’s office, outpatient facility, emergency room/department, or inpatient facility). AmeriHealth routinely audits the claims we adjudicate to ensure they are paid accurately and in accordance with the member’s benefit plan. Audits include, but are not limited to, ensuring appropriate application of cost-sharing. If a claim adjustment is required based

on audit findings, it will be noted on the Statement of Remittance that you receive through the normal course of business.

Verifying member eligibility and cost-sharing amountsTo verify member eligibility and cost-sharing amounts, providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal. For information on using this transaction, please review the Eligibility and Benefits Inquiry Guide, which is available in the NaviNet Transaction Changes section of our Upcoming System and Process Changes site at www.amerihealth.com/pnc/upcomingchanges.

If you are not NaviNet-enabled, you can sign up by going to the NaviNet website at www.navinet.net and selecting Sign Up at the top of the page.

Note: Cost-sharing amounts are available to members through their benefit plan documents or by logging on to our secure member website, amerihealthexpress.com.

Provider Automated System not available for migrated AmeriHealth Pennsylvania membersThis article is a reminder about the retirement of the Provider Automated System. Please read this notice carefully if you currently use the Provider Automated System, as your day-to-day operations may be affected.

As previously communicated, the Provider Automated System is no longer available for submitting or retrieving referrals or submitting encounters. Primary care physicians should use the NaviNet® web portal to submit encounter data and referrals to AmeriHealth (paper referrals and encounters are not permitted by AmeriHealth).

Visit our Upcoming System and Process Changes site at www.amerihealth.com/pnc/upcomingchanges frequently for the most up-to-date information about this transition. A Frequently Asked Questions document and communication archive are available on this site for your reference.

Note: All participating providers were required to register for NaviNet by April 1, 2013. If you have not yet done so, go to www.navinet.net and select Sign Up from the top right. If your office is currently NaviNet-enabled but would like training, please contact our eBusiness Provider Hotline at 215-640-7410 for providers in Pennsylvania and Delaware or at 609-662-2565 for providers in New Jersey.Starting January 1, 2014, and continuing

through mid-2015, AmeriHealth will be migrating AmeriHealth Pennsylvania members to a new operating platform. Once an AmeriHealth Pennsylvania member has been migrated to the new platform, you will no longer be able to use the Provider Automated System for that member. This includes all additional functionality, such as eligibility and claims status. You must use NaviNet for this information.

www.amerihealth.com/pnc/upcomingchanges


Billing

Revised time line for new CMS-1500 (02/12) claim formThe National Uniform Claim Committee (NUCC) has approved an updated version of its 1500 Health Insurance Claim Form (CMS-1500 claim form). The new claim form, which goes into effect January 6, 2014, will accommodate reporting needs for ICD-10 as well as align with data captured on electronic 837P transactions. The primary change to the form is that the number of diagnosis codes that can be reported has been increased from four to 12 (see sample below).

Revised: AmeriHealth will accept both the old (08/05) and new (02/12) claim forms from January 6 through March 31, 2014. Effective April 1, 2014, providers should use the new (02/12) claim form. As of October 1, 2014, AmeriHealth will no longer accept claims using the old (08/05) claim form.

The NUCC has released an updated 1500 Health Insurance Claim Form Reference Instruction Manual, which is available under the 1500 Claim Form tab on their website at www.nucc.org.

Forms can be purchased through office supply stores, local printing companies, or by calling the U.S. Government Printing Office at 1-866-512-1800.

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

Additional 8 fields added for a total of 12. Alpha field labels added.


Billing

Enforcement of industry standards related to platform transition for AmeriHealth Pennsylvania membersStarting January 1, 2014, we will begin transitioning our AmeriHealth Pennsylvania membership to the new operating platform. As a result, we will be enforcing industry standards for claims processed on the new platform. If you have been submitting claims based on industry standards, as has been communicated to you in the past, you will have no issues with the topics noted below. However, if you have not, please be advised that you will see an increase in rejections and/or claim denials for claims processed on the new platform.

These standards include, but are not limited to, the following:

● NAIC code. The payer NAIC code must be the same as the claim and envelope layers’ Receiver and Payer codes. In addition, please refer to the payer ID grids at www.amerihealth.com/edi to ensure that you submit claims with the appropriate NAIC code, as identified in the Payer Information column and in accordance with the member’s coverage. This will direct your claims to the correct operating platform for processing.

● Interim billing claims. Interim billing claims are not accepted from acute care facilities for inpatient claims. Acute care facilities are required to submit claims after the member is discharged.

● Occurrence code M0. Occurrence code M0 (zero) must be reported with Condition Code C3.

● Missing procedure description. A description is required for all non-specific codes (i.e., not otherwise classified [NOC]; unspecified; other; miscellaneous; prescription drug, generic; or prescription drug, brand name).

● Invalid revenue codes. The “001” revenue code is meant to indicate the total charge, and it should no longer be submitted at the service line level. The total charge should only be in the total charge field at the claim level.

● Room and board. A room and board revenue code is required for all inpatient bill types.

● NPI/Taxonomy code. The provider’s National Provider Identifier (NPI) must be billed with the corresponding taxonomy code.

● Operating physician requirement. If a claim has a surgical revenue code with a surgical procedure code, the operating physician is required.

● Referring provider. The referring provider is required on all claims when place of service 81 (i.e., independent clinical lab) is used.

For more information about our transition to the new platform for AmeriHealth Pennsylvania members, please visit our Upcoming System and Process Changes site at www.amerihealth.com/pnc/upcomingchanges. On this site, you will find a communication archive and Frequently Asked Questions (FAQ) document. If you still have questions after reviewing the FAQ, email us at [email protected].

Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2014Effective January 1, 2014, we will implement a quarterly update to our Professional Injectable and Vaccine Fee Schedule for all contracted providers. These updates reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables.

If you have any questions about the updates or where you can view them, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.


Billing

Medically Unlikely Edits now applied to professional and facility claims for AmeriHealth Pennsylvania membersAs previously communicated, AmeriHealth is making system and process changes that will affect the way we do business with you. As a result, there will be a change to the processing of claim service units for professional claims for AmeriHealth Pennsylvania members, effective November 1, 2013. Medically Unlikely Edits (MUE) will now be applied to professional claims, in addition to facility claims.

AmeriHealth claims will continue to be adjudicated using the Centers for Medicare & Medicaid Services (CMS) MUEs for facility claims as referenced in Bulletin #08-2010: Fee Schedule Update and Reminders for Billing Outpatient Units of Service and ER Follow-Up Care.

An MUE is assigned to certain HCPCS/CPT® codes identifying the maximum units of service a provider performs on a patient on a given date of service.

Note: Claim lines with billed units that exceed CMS-published MUE values will be rejected. Claims reported with ICD-9 procedure codes are not affected.

For a complete listing of CMS-published MUE values, go to www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html.

For more information about our upcoming system and process changes, please visit our dedicated site at www.amerihealth.com/pnc/upcomingchanges.

medicAl

Reminder: Updates to precertification requirements effective January 1, 2014Effective January 1, 2014, AmeriHealth will use a single precertification requirement list across all managed care products. This change is being made as we continue to look for ways to improve and simplify the precertification process.

Significant changes will be made to the precertification requirements for the following three categories effective January 1, 2014:

● Outpatient surgical procedures. For standard HMO products, not all outpatient surgical procedures will require precertification. Only select outpatient surgical procedures will be included on the precertification requirement list.

● Durable medical equipment (DME) and prosthetic items. Currently, precertification is required for all rentals and purchases of DME and prosthetic items that cost more than $500. Effective January 1, 2014, only certain DME and prosthetic items will require precertification, regardless of the cost of these items.

● Injectable and infusion therapy drugs. Precertification requirements will be added for Acthar H.P.®, Adcetris®, Kyprolis®, Naglazyme®, Perjeta®, Simponi® Aria, Veletri®, and Xofigo®. Precertification approval will no longer be required for Lucentis®, Macugen®, Mozobil®, and Temodar®. In addition, precertification requirements for 23 drugs will be removed for AmeriHealth Pennsylvania members who have Flex products. The drugs include Aranesp®, Neulasta®, and Eligard®.

These changes are reflected on the precertification requirement list available at www.amerihealth.com/preapproval.

If you have any questions, please contact Cheryl McGurk, manager of precertification, at 215-241-4542.

www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html


medicAl

continued on the next page

Policy notifications posted as of November 25, 2013 All policies are posted prior to their effective date. Below is a listing of the policy notifications that we have posted to our website as of November 25, 2013.

Policy effective date Policy No. Notification titleNotification issue date

November 27, 2013 07.10.05aNoncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System

August 28, 2013

December 10, 2013 05.00.73aNeuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)

September 11, 2013

December 10, 2013 11.01.06aBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids

September 11, 2013

December 26, 2013 06.03.04h Apheresis Therapy September 27, 2013

December 26, 2013 11.01.02j Cochlear Implant September 27, 2013

January 1, 2014 05.00.24jInterstitial Continuous Glucose Monitoring Systems (CGMSs)

October 3, 2013 (Revised Nov. 25, 2013)

January 1, 2014 05.00.39i Ankle-Foot/Knee-Ankle-Foot Orthosis October 3, 2013

January 1, 2014 07.00.03kFull-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy

October 3, 2013 (Revised Nov. 25, 2013)

January 1, 2014 07.00.20eRoutine Costs Associated with Qualifying Clinical Trials

October 3, 2013

January 1, 2014 07.03.05p Sleep Disorder Testing October 3, 2013

January 1, 2014 07.05.02jWireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

October 3, 2013

January 1, 2014 07.10.05bNoncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System

November 20, 2013

January 1, 2014 08.00.13oImmune Globulin Intravenous (IVIG), Subcutaneous (SCIG)

October 3, 2013

January 1, 2014 08.00.78j Self-Administered Drugs October 3, 2013

January 1, 2014 08.00.92e Coagulation Factors for Hemophilia October 3, 2013

January 1, 2014 10.03.01cPhysical Medicine, Rehabilitation, and Habilitation Services

October 3, 2013

January 1, 2014 11.07.01lHematopoietic Stem Cell Transplantation (Bone Marrow Transplant)

October 3, 2013

January 1, 2014 11.14.24 Manipulation under Anesthesia October 3, 2013

January 7, 2014 07.03.08d Neuropsychological Evaluation/Testing October 9, 2013

February 4, 2014 11.08.02f Reduction Mammoplasty November 6, 2013

February 5, 2014 05.00.42e Patient Lifts November 6, 2013

February 5, 2014 11.14.10kPercutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty

November 6, 2013

February 5, 2014 07.00.02g Intravenous Chelation Therapy November 7, 2013

February 18, 2014 07.02.03g Implantable Cardiac Loop Monitor November 20, 2013

February 19, 2014 11.02.12ePercutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery

November 20, 2013


Policy notifications posted as of November 25, 2013 (continued)

medicAl

Coverage for certain surgical proceduresEffective January 1, 2014, based on local practice patterns, AmeriHealth will consider the procedures listed below to be outpatient procedures, as they are being performed mainly in the outpatient setting and generally no longer require inpatient hospitalization.

The following is a list of procedures that will be considered outpatient procedures for dates of service on or after January 1, 2014:

● thyroidectomy – partial or total

● parathyroidectomy

● recurrent hernia

● temporomandibular joint (TMJ) arthroplasty and discectomy

● arthroscopy (shoulder, elbow, wrist)

● open reduction internal fixation of uncomplicated wrist or finger fractures

We ask that providers perform these procedures as outpatient; however, if you feel there are medical reasons that would justify an inpatient stay, AmeriHealth will review these upon request and approve the inpatient setting if medically appropriate. If we approve these procedures as inpatient and the patient goes home the same day, we will reimburse these procedures as outpatient. You may direct your review requests to the Precertification Department by calling 1-800-275-2583 for providers in Pennsylvania and Delaware or 1-888-YOUR-AH1 (1-888-968-7241) for providers in New Jersey and saying Authorizations.

Please note that as of January 1, 2014, none of the procedures listed above will require precertification if performed in the outpatient setting.

If you have any questions about this notice or criteria for the above procedures, please contact Pamela Weatherbee, Manager of Care Management Coordination, at 215-241-9449.

Coverage for injectable drugs that reduce the risk of preterm birthFor pregnant women who have a history of preterm birth, AmeriHealth covers two injectable drugs to reduce the risk of preterm birth:

● the preservative-free compound 17-alpha-hydroxyprogesterone caproate (17P)

● Makena®, which is approved by the U.S. Food and Drug Administration

Both drugs use the same active pharmaceutical ingredients and are available through the AmeriHealth Direct Ship Injectables Program, but Makena contains preservatives as a result of the manufacturing process. Providers are encouraged to select the drug that is appropriate for each individual patient, given her unique circumstances.

For more information about 17P and Makena, visit www.amerihealth.com/medpolicy to review Medical Policy #08.01.00c: Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies.

Policy effective date Policy No. Notification titleNotification issue date

February 19, 2014 11.11.01fEvaluation and Treatment of Erectile Dysfunction (ED)

November 21, 2013

To view the policy notifications, go to www.amerihealth.com/medpolicy, select Accept and Go to Medical Policy Online, and click on the Policy Notifications box. You can also view policy notifications using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Once these policies are in effect, they will be available by using the Search box on the Medical Policy homepage. Be sure to check back often, as the site is updated frequently.


medicAl

Changes to sleep study precertification requirements for Medicare Advantage HMO membersAs previously communicated, effective for dates of service on or after January 1, 2014, precertification is required for Medicare Advantage HMO members for sleep studies and continuous positive airway pressure (CPAP) titration in the facility setting (free-standing sleep study center or hospital sleep study lab). Note: This change was implemented for commercial members on September 1, 2013.

AmeriHealth New Jersey has delegated the responsibility for precertification of sleep studies and CPAP titration studies in the facility setting to AIM Specialty HealthSM (AIM). AIM uses their Sleep Disorder Management Diagnostic & Treatment Guidelines, adopted by AmeriHealth New Jersey and available on their website at www.aimspecialtyhealth.com, to guide the utilization of these services for our members. The guidelines involve integration of medical information from multiple sources to support the use of high-quality and state-of-the-art advanced sleep management services. The process for criteria development is based on technology assessment and peer-reviewed medical literature, including clinical outcomes research and consensus opinion in medical practice. It takes into consideration recommendations from:

● American Academy of Sleep Medicine (AASM)

● American Thoracic Society (ATS)

● Agency for Healthcare Research and Quality (AHRQ)

● Centers for Medicare & Medicaid Services (CMS)

AmeriHealth New Jersey covers sleep studies conducted in the home setting, without precertification, when the medical necessity criteria outlined in Medical Policy #07.03.05o: Sleep Disorder Testing are met (#07.03.05p as of January 1, 2014). Precertification is not required for sleep studies that are conducted in the home setting. CPAP titration in the home setting continues to require precertification through AmeriHealth New Jersey, based on the standard rules for rental of durable medical equipment.

Members should obtain sleep studies and CPAP titration in the setting that is most appropriate for their condition, based on factors such as:

● the setting that has been determined to be both cost-effective and safe for the member;

● the level of care required by the member based on his or her medical history and current health status;

● current standards in medical practice.

Member cost-sharing (deductible, coinsurance, and/or copayments) applies in accordance with the terms of the member’s benefit contract.

Obtaining precertification for the sleep studies in the facility settingProviders who request coverage for administration of a sleep study in a facility setting are required to provide details about the member’s medical history to support the request.

All precertification requests for sleep studies and CPAP titration in a facility setting should be submitted through the AIM ProviderPortalSM, which can be accessed through the NaviNet® web portal by selecting Authorizations from the Plan Transactions menu, then AIM.

It is very important that providers use NaviNet to verify member-specific requirements or refer to the most current precertification requirement list on our website at www.amerihealth.com/preapproval. Failure to obtain precertification for any of the services that require it may result in a reduction in payment or nonpayment for the services not precertified.

If you have any questions about these changes to place-of-service options for sleep studies, please call Customer Service at 1-888-YOUR-AH1 (1-888-986-7241).


PhArmAcy

Select Drug Program® Formulary updatesThe Select Drug Program Formulary is a list of medications approved by the U.S. Food and Drug Administration that were chosen for formulary coverage based on their medical effectiveness, safety, and value. The list changes periodically as the Pharmacy and Therapeutics Committee reviews the formulary to ensure its continued effectiveness. The most recent changes are listed below.

Generic additionsThese generic drugs recently became available in the marketplace. When these generic drugs became available,

we began covering them at the appropriate generic formulary level of cost-sharing:

Generic drug Brand drug Formulary chapter Effective date

acitretin Soriatane® 5. Skin Medications July 25, 2013

alendronate sodium solution Fosamax® solution

10. Female, Hormone Replacement, & Birth Control

April 26, 2013

candesartan cilexetil Atacand® 4. Heart, Blood Pressure, & Cholesterol May 23, 2013

chorionic gonadotropin Novarel®/Pregnyl®

15. Diagnostics & Miscellaneous January 1, 2014

dihydrocodeine/aspirin/caffeine Synalgos®-DC 3. Pain, Nervous System, & Psych May 31, 2013

fenofibric acid (choline) Trilipix® 4. Heart, Blood Pressure, & Cholesterol July 19, 2013

metronidazole topical gel Metrogel® 5. Skin Medications July 3, 2013

omeprazole suspension First®-Omeprazole

8. Stomach, Ulcer, & Bowel Meds June 28, 2013

quazepam Doral® 3. Pain, Nervous System, & Psych July 12, 2013

repaglinide Prandin®7. Diabetes, Thyroid, Steroids, & Other

Miscellaneous HormonesJuly 25, 2013

riluzole Rilutek® 3. Pain, Nervous System, & Psych June 7, 2013

zolmitriptan Zomig®, Zomig-ZMT®

3. Pain, Nervous System, & Psych May 17, 2013


Reminder about the Preventive Medication Program included in our prescription drug plan

Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA), including generic products and those brand products that do not have a generic equivalent, are covered without cost-sharing with a doctor’s prescription when provided by a participating retail or mail-order pharmacy. Coverage includes certain products within the following drug categories: (1) aspirin to prevent cardiovascular disease for men age 45-79 and women age 55-79, (2) breast cancer chemotherapy prevention for women, (3) fluoride supplementation for children 6 months through 6 years, (4) folic acid supplementation for women planning or capable of pregnancy, (5) iron supplementation for children ages 6 to 12 months who are at increased risk for iron deficiency anemia, (6) tobacco interventions for adults who use tobacco products, and (7) vitamin D supplementation for ages 65 and over to prevent falls.

Contraceptives, mandated by the Women’s Preventive Services provision of the PPACA, are covered at 100 percent when provided by a participating provider for generic products and for those brand products that do not have a generic equivalent. Brand contraceptive products with a generic equivalent are covered at the brand cost-sharing level for the member’s plan.


PhArmAcy

Select Drug Program® Formulary updates (continued)

Brand additionsThese brand drugs were added to the formulary as of the dates indicated below

and are covered at the appropriate brand formulary level of cost-sharing:

Brand drug Formulary chapter Effective date

Advate® 15. Diagnostics & Miscellaneous January 1, 2014

Alphanate® 15. Diagnostics & Miscellaneous January 1, 2014

Alphanine® SD 15. Diagnostics & Miscellaneous January 1, 2014

Bebulin® 15. Diagnostics & Miscellaneous January 1, 2014

BeneFIX® 15. Diagnostics & Miscellaneous January 1, 2014

Cialis® 13. Urinary & Prostate Meds October 1, 2013

Feiba NF® 15. Diagnostics & Miscellaneous January 1, 2014

Helixate® FS 15. Diagnostics & Miscellaneous January 1, 2014

Hemofil® M 15. Diagnostics & Miscellaneous January 1, 2014

Humate-P® 15. Diagnostics & Miscellaneous January 1, 2014

Koate®-DVI 15. Diagnostics & Miscellaneous January 1, 2014

Kogenate® FS 15. Diagnostics & Miscellaneous January 1, 2014

Lialda® 3. Pain, Nervous System, & Psych November 1, 2013

Liptruzet™ 4. Heart, Blood Pressure, & Cholesterol November 1, 2013

Monoclate-P® 15. Diagnostics & Miscellaneous January 1, 2014

Mononine® 15. Diagnostics & Miscellaneous January 1, 2014

NovoSeven® RT 15. Diagnostics & Miscellaneous January 1, 2014

Profilnine® SD 15. Diagnostics & Miscellaneous January 1, 2014

Recombinate™ 15. Diagnostics & Miscellaneous January 1, 2014

Vascepa® 4. Heart, Blood Pressure, & Cholesterol November 1, 2013

Wilate® 15. Diagnostics & Miscellaneous January 1, 2014

Xarelto® 4. Heart, Blood Pressure, & Cholesterol November 1, 2013

Xyntha® 15. Diagnostics & Miscellaneous January 1, 2014


PhArmAcy

Select Drug Program® Formulary updates (continued)

Brand deletionsThese brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Effective January 1, 2014.

Brand drugFormulary Therapeutic Alternatives

Formulary chapter

Cortef® 5mg, 10 mg hydrocortisone 9. Bone, Joint, & Muscle

Efudex® fluorouracil 5. Skin Medications

Lanoxin® digoxin 4. Heart, Blood Pressure, & Cholesterol

Metrogel® metronidazole topical gel 5. Skin Medications

Prandin® repaglinide7. Thyroid, Steroids, & Other Miscellaneous

Hormones

Trilipix® fenofibric acid (choline) 4. Heart, Blood Pressure, & Cholesterol

The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level of cost-sharing.



PhArmAcy

Prescription drug updates For members enrolled in an AmeriHealth prescription drug program, prior authorization and quantity limit requirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medically necessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medication based upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for a particular drug. The most recent updates are reflected below.

Drugs requiring prior authorizationThe prior authorization requirement for the following non-formulary drugs was effective at the time the drugs became available in the marketplace:

Brand drug Generic drug Drug category Effective date

Mekinist® Not available Cancer & Organ Transplant Drugs June 21, 2013

Tafinlar® Not available Cancer & Organ Transplant Drugs June 14, 2013

Vecamyl™ Not available Heart, Blood Pressure, & Cholesterol May 3, 2013

Drugs requiring prior authorizationThe following non-formulary drugs have been added to the list of drugs requiring prior authorization:


Brand drug Generic drug Drug category

Adrenaclick®, Auvi-Q® epinephrine pen Allergy, Cough & Cold, Lung Meds

Alodox® doxycycline Antibiotics & Other Drugs Used for Infection

Avidoxy™, Monodox®, Adoxa®

doxycycline monohydrate

Antibiotics & Other Drugs Used for Infection

Doryx® DR, Vibramycin®

doxycycline hyclate Antibiotics & Other Drugs Used for Infection

Esomeprazole Strontium

Not available Heart, Blood Pressure, & Cholesterol

Minocin® minocycline hcl Antibiotics & Other Drugs Used for Infection

Novarel®, Pregnyl®chorionic gonadotropin, human

Diagnostics & Miscellaneous

Rescula® Not available Eye Medications

Drugs no longer requiring prior authorizationPrior authorization has been removed for the following drug:

Effective November 1, 2013.

Brand drug Generic drug Quantity limit

Vascepa® Not available 4. Heart, Blood Pressure, & Cholesterol


Drugs with quantity limitsQuantity limits will be added for the following drugs:


Brand drug Generic drug Quantity limit

All applicable products blood glucose monitors 1 per year

All applicable products diabetic test strips 200 per 30 days

All applicable products lancets 200 per 30 days

All applicable products insulin injecting devices 2 per year

All applicable products insulin syringes and pen needles 200 per 30 days

Ella® ulipristal acetate 3 per 30 days

Firazyr® Not available27 ml per 30 days (9 syringes)

My Way®, Next Choice® One Dose, Plan B® One-Step

levonorgestrel 1.5 mg 3 per 30 days

Not available hydrocodone/chlorpheniramine 450 ml per 30 days

Nicotrol® NS nicotine nasal spray 80 ml per 30 days

Plan B® levonorgestrel .075 mg 6 per 30 days

Prescription drug updates (continued)

PhArmAcy


December 2013 | Partners in Health UpdateSM 17 www.amerihealth.com/providersDecember 2013 | Partners in Health UpdateSM 17 www.amerihealth.com/providers

Putting ICD-10 into Practice: Coding exercises and scenarios


Throughout 2013, we have published an assortment of coding examples and scenarios to help you put the new ICD-10 guidelines and conventions into practice. This final article in the series will review some of those exercises.

An answer key is provided below so you can verify if your answers are correct. In addition, code narratives are included on the next page to describe each ICD-10 code used in the exercises. If needed, use the ICD-10 Spotlight: Know the codes booklet for assistance with these exercises. It is available at www.amerihealth.com/icd10.

Coding exercises Code the following conditions according to ICD-10 coding conventions and guidelines:

1. Subsequent encounter for obesity resulting from the prescription drug Tryptanol®

2. Morbid obesity with a Body Mass Index (BMI) of 42 in an adult

3. Concussion without loss of consciousness, initial encounter with neck pain

4. Twin pregnancy, one placenta, two amniotic sacs, third trimester with complication of gestational hypertension

5. Hypotension due to drugs (diuretics), initial encounter

6. Cardiomyopathy from alcohol abuse

7. Uterine prolapse, first degree and third degree

8. Plaque psoriasis

9. Senile dementia

10. Churg-Strauss syndrome

11. Aphakia of right eye (due to trauma)

Answers to coding exercises:

1) E66.1, T43.015D 2) E66.01, Z68.41 3) S06.0x0A, M54.2 4) O30.033, O13.3 5) I95.2, T50.2x5A 6) N81.2, N81.3 7) I42.6, F10.99 8) L40.0

9) F03.90 10) M30.1 11) H27.01


Putting ICD-10 into Practice: Coding exercises and scenarios (continued)

Are you ready for ICD-10?If you aren’t ready for ICD-10 by October 1, 2014, your payments may be affected. Visit our dedicated website at www.amerihealth.com/icd10 today for resources and more information.

Please visit the ICD-10 section of our website at www.amerihealth.com/icd10. On this site you will find additional information related to the transition to ICD-10, including frequently asked questions, examples of how ICD-9 codes will translate to ICD-10 codes in the ICD-10 Spotlight: Know the codes booklet, and ICD-10 coding exercises and scenarios in the Putting ICD-10 into Practice: Coding exercises and scenarios booklet.

NarrativesThe following are the corresponding code narratives for each of the codes in the answer key:

ICD-10 code Code narrative

E66.1 Drug-induced obesity

T43.015D Adverse effect of tricyclic antidepressants, subsequent encounter

E66.01 Morbid (severe) obesity due to excess calories

Z68.41 Body mass index (BMI) 40.0-44.9, adult

S06.0x0A Concussion without loss of consciousness, initial encounter

M54.2 Cervicalgia

O30.033 Cyclophoria

O13.3 Gestational (pregnancy-induced) hypertension without significant proteinuria, third trimester

I95.2 Hypotension due to drugs

T50.2x5AAdverse effect of carbonic-anhydrase inhibitors, benzothiadiazides, and other diuretics, initial encounter

N81.2 Incomplete uterovaginal prolapse

N81.3 Complete uterovaginal prolapse

I42.6 Alcoholic cardiomyopathy

F10.99 Alcohol use, unspecified with unspecified alcohol-induced disorder

L40.0 Psoriasis vulgaris

F03.90 Unspecified dementia without behavioral disturbance

M30.1 Polyarteritis with lung involvement (Churg-Strauss)

H27.01 Aphakia, right eye


Products

AmeriHealth New Jersey products available both on and off the Health Insurance MarketplaceAs previously communicated, AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (AmeriHealth New Jersey) have begun offering new qualified health plans both on and off the Health Insurance Marketplace. These commercial products are available to small groups and individuals for coverage beginning January 1, 2014.

Starting January 1, 2014, you may begin to see members with these new products. Their member ID cards will include standard information, such as the network name and basic copayments for primary care and specialist services. In addition, these products will follow our current administrative, claims payment, and medical policies. Providers participating with AmeriHealth New Jersey will be participating providers for these products by virtue of the network in which they are currently contracted. Participating providers will be reimbursed in accordance with their payment rates for commercial products.

EPO tiered productsIncluded in these new commercial products are two tiered EPO products:

● Cooper Advantage. This product was developed for residents and small employers headquartered in Burlington, Gloucester, and Camden counties. Members who purchase this product will have access to participating providers in the Value Network. Within that network, facility and professional providers will be assigned to one of two tiers. Tier 1 will be comprised of mostly Cooper facilities and physicians, and members will have lower out-of-pocket costs for most services when using these providers.

● Tier 1 Advantage. This product will be available to New Jersey residents and employers statewide. Members who purchase this product will have access to participating providers in the Value Network. Within that network, hospitals and ambulatory surgical centers will be assigned to one of two tiers based on cost. Lower-cost facilities will be placed in Tier 1, and members will have lower out-of-pocket costs for most services when using Tier 1 providers.

When seeing members covered under either of these two tiered products, please take into consideration the benefit tier placement for facilities that you are affiliated with or may refer members to, as this will affect members’ out-of-pocket costs. You can review benefit tier placements by searching for specific providers on our website at www.amerihealthnj.com by selecting the Search button under Find a Provider.

Note: The NaviNet® web portal will be updated to provide the correct tier cost-sharing for members with these products. Please continue to use NaviNet as you do today to confirm member eligibility and benefits.

For more information about these commercial products, please refer to the November 2013 edition of Partners in Health Update. If you have any questions, please email our Provider Relations Services team at [email protected].


nAvinet®

New NaviNet functionality for ePayment, Cap Rosters, and other transactionsThis month, you will see additional changes to the NaviNet web portal as we continue to transition our claims processing for AmeriHealth Pennsylvania members to a new operating platform. This article describes new transactions that will be introduced starting December 13, 2013.

Reminder: When conducting transactions from AmeriHealth NaviNet Plan Central, search results will include information only for members covered under AmeriHealth plans. Please ensure you have access to all applicable health plans you do business with.

EOB and Remittance InquiryStarting December 13, 2013, the new EOB and Remittance Inquiry transaction will be made available to all participating providers who are NaviNet-enabled (i.e., no enrollment for the transaction is necessary). This transaction will provide claims payment information for finalized claims processed after December 13, 2013, on the new platform.

To access the transaction, select ePayment from the Plan Transactions menu, and then EOB and Remittance Inquiry. Your designated Security Officer will have immediate access to the transaction once it’s available; he or she will manage access for applicable staff through the User Management transaction.

Through this transaction, providers will be able to download and/or print their Provider Explanation of Benefits (EOB) (for professional providers) or Provider Remittance (for facility providers). Providers will also be able to search for statements in two-week increments. In addition, beginning December 13, 2013, providers will start building a history of stored statements – ultimately having four months of historical remittance data available. For this reason, it will be important to download and save reports on a regular basis.

The statements will include A/R detail, when appropriate. A single Provider EOB or Provider Remittance may contain multiple PDF documents. The various payment types include:

● spending account payment

● remittance payment

● facility remittance

Guides to help you interpret your Provider EOB or Provider Remittance will be available soon on the Upcoming System and Process Changes site at www.amerihealth.com/pnc/upcomingchanges. Look for more information about these guides in future editions of Partners in Health Update.

For claims with service dates that span migrationProviders currently enrolled for the Online Statement of Remittance (SOR) will continue to have access to remittance data for claims processed on the current platform (i.e., for AmeriHealth New Jersey and Delaware members and AmeriHealth Pennsylvania members who have not yet been migrated to the new platform). When the claim service date range spans migration (i.e., dates of service prior to and post member migration), you can expect the following:

● Facility claims. If the date of admission occurred prior to the member’s migration, the claim will be processed on the current platform, and resulting remittance data will be available through the Online SOR transaction. If the date of admission occurred after the member was migrated, the claim will be processed on the new platform, and the resulting remittance data will be available through the new EOB and Remittance Inquiry transaction.

● Professional claims:

– If the date of service is before the member is migrated to the new platform: The claim will be processed on the current platform, and the resulting remittance data will be available through the Online SOR transaction.

– If the date of service is after the member is migrated to the new platform: The claim will be processed on the new platform, and the resulting remittance data will be available through the new EOB and Remittance Inquiry transaction.

– If dates of service include dates both pre- and post-member migration: The claim will be split. For dates of service prior to member migration, the specified service lines will be processed on the current platform, and the resulting remittance data will be available through the Online SOR transaction. For dates of service after member migration, the specified service lines will be processed on the new platform, and the resulting remittance data will be available through the new EOB and Remittance Inquiry transaction.



nAvinet®

Cap Rosters Updated Cap Roster transactions will be available starting December 13, 2013. Please note that these transactions will only include information for AmeriHealth members.

For the transactions detailed in this section, you will need to select the month from the search screen. You will also have the option to search by provider group or tax ID number. The report itself will include summary and detail sections. Within the detail section, you will be able to sort the columns as needed. You will also have a new search text field, which will allow you to customize a filter.

Refer to the following for information specific to each transaction:

● PCP Capitation Rosters. To access primary care physician (PCP) reports, continue to select ePayment from the Plan Transactions menu, and then PCP Cap Rosters. Up to 13 months of historical data will be available.

● Specialist Capitation Rosters. Capitation rosters will be available for our specialist radiology and physical therapy providers. Our capitated facilities and capitated specialists will have access to these rosters. Your designated Security Officer will control user access. To access capitation rosters, select ePayment from the Plan Transactions menu, and then Specialist Cap Rosters. The January 2014 report will be the first one available to you. With each new month, you will begin to build a history of stored reports. Ultimately, up to 13 months of historical data will be available.

Note: If you are enabled for electronic funds transfer (EFT), you will no longer receive paper rosters/reports for migrated members. All EFT-enabled providers must access capitation rosters using NaviNet.

Claims Investigation (Claims INFO)The Plan Transactions menu will no longer include the Claims INFO Adjustment Submission transaction as a stand-alone option. Claims adjustment requests will be submitted through the new Claims Investigation transaction. Access Claims Investigation by using the link provided on the Claim Status Inquiry Summary or Detail Screens. Only finalized claims (i.e., paid or denied) will display the link for Claims Investigation.

Providers who access a claim through the Claim Status Inquiry transaction can expect the following:

● For finalized claims processed on the current platform (i.e., for non-migrated members): Providers

will be offered the new Claims Investigation link. Providers can submit an adjustment for an individual claim and will be permitted to edit the claim (including the ability to submit late charges).

● For finalized claims on the new platform (i.e., for migrated AmeriHealth Pennsylvania members): Providers will be offered the new Claims Investigation link. The transaction will allow providers to submit an adjustment for an individual claim and will permit limited claim editing (excluding the ability to submit late charges). When initiating an adjustment, you will be requested to select one of the following Adjustment Types:

– Claim Denied No Auth/Referral

– Claim Paid Low Level in Error

– Claim Pending over 45 Days

– COB Related – Discrepancy on How Claim Processed

– Follow Up to Previous Investigation

– Medicare Related – Membership/Enrollment Denial

– NIA Retrospective Review

– Refund Request/Check Reissue

After selecting the Adjustment Type, proceed to the provided text box to indicate the details of your request. Individual claim service lines will no longer be provided, and your contact information and telephone number continue to be required fields. You will receive a response message after submitting your adjustment; however, a unique adjustment ID will not be assigned. If you need to add late charges or make other significant changes to the original claim, you will need to submit a corrected claim through your normal claim processing channels.

The Plan Transactions menu will also no longer include the Claims INFO Adjustment Inquiry transaction as a stand-alone option. To check the status of a previously submitted adjustment request, use the new Claims Investigation Inquiry transaction. After selecting your provider group, complete the Request Date To and Request Date From fields. Note: The Request Date To will default to today’s date, and the Request Date From will default to 30 days prior to the current date. You can modify these dates, but the date span cannot exceed one month. Up to 18 months of historical data will be available to you. Other optional fields are also available for the Adjustment ID or Investigation Status (open/closed).

New NaviNet functionality for ePayment, Cap Rosters, and other transactions (continued)



nAvinet®

AuthorizationsEffective January 1, 2014, all managed care products will follow the same precertification requirement list. For more structured plans (i.e., HMO, POS), this equates to a reduction in authorizations and an easing of administrative effort. HMO members will still require a referral to see a specialist, but not for the procedure itself, and they must see a provider participating in HMO network for coverage. For PPO plans, this means a change in the type of procedures that will require authorization and a slight increase in volume.

These changes will be reflected in four key authorization transactions: Medical/Surgical Pre-Authorization; Chemotherapy/Infusion Therapy Authorization; Durable Medical Equipment (DME); and Speech Therapy Authorization. Some of the changes will include the following:

● Only certain outpatient and office procedures will require authorization.

● Only certain drugs/infusions will require authorization, and it is no longer dependent on setting.

● Only certain DME items will require authorization.

● No authorization will be required for speech therapy.

Please refer to the Reminder: Updates to precertification requirements effective January 1, 2014 article in this edition of Partners in Health Update for more specific information about these changes.

For more informationTo help you better understand these changes, new user guides will be made available soon that will describe these transactions in greater detail. We encourage you to review these new guides when they are published in the NaviNet Transaction Changes section of our Upcoming System and Process Changes site at www.amerihealth.com/pnc/upcomingchanges.

Announcements will be made on AmeriHealth NaviNet Plan Central and on our Provider News Center at www.amerihealth.com/pnc once the new guides are posted.

If you have any questions regarding the NaviNet transaction changes, please call the eBusiness Hotline at 215-640-7410 for providers in Pennsylvania and Delaware and at 609-662-2565 for providers in New Jersey.

Standards for medical record documentationDocumentation of preventive health screenings is an essential part of comprehensive quality care. In addition to keeping medical records for patients’ regular check-ups, it is important to have a record for patients who are seen only for acute care visits or whom you see at multiple visits for management of chronic conditions.

Some practices use a separate form designed specifically for yearly well-visits to capture physical evaluation and preventive care assessments. This allows for accurate tracking of preventive care screenings and routine health assessment documentation.

The following tips can help you maintain necessary medical record documentation:

● Remember to review preventive health and cancer screenings with each patient on an annual basis.

● Review Clinical Alerts* provided by AmeriHealth via the NaviNet® web portal prior to scheduled visits to identify and address gaps in care.

● Remind female patients covered under an HMO plan about Direct Access OB/GYNSM and mammography screenings.

For practices that use electronic medical records (EMR), finding a program that contains specific screens to capture preventive health care measures may be helpful in providing consistent quality care to your patients.

For more information on Clinical Alerts*, please review the Clinical Alerts Overview, which is located in the Administrative Tools & Resources section of AmeriHealth NaviNet Plan Central.

Standards for maintaining appropriate medical records can be found in the Provider Manual for Participating Professional Providers (Provider Manual), which is available on AmeriHealth NaviNet Plan Central. A paper copy of the Provider Manual can be ordered by submitting an online request or by calling the Provider Supply Line at 1-800-858-4728.

* The Clinical Alerts feature is currently disabled but access will be re-established in mid-December.

QuAlity mAnAgement

New NaviNet functionality for ePayment, Cap Rosters, and other transactions (continued)

www.amerihealth.com/pnc/upcomingchanges

QuAlity mAnAgement


Our Quality Management Program promotes quality of care and serviceInformation about the AmeriHealth Quality Management Program is accessible on our website at www.amerihealth.com/qualitymanagement. AmeriHealth is dedicated to maintaining the highest standard of care and service for our members, providers, and the communities we serve. The following information about our Quality Management Program is available on our website to promote our standards of care:

● Quality Management Program. The description of the AmeriHealth Quality Management Program includes program goals, objectives, and activities to improve clinical, network, and service quality.

● Member rights and responsibilities. All AmeriHealth members have defined rights and responsibilities.

● Medical record-keeping standards. Well-maintained medical records are critical to facilitate communication, continuity, coordination, and an effective plan of care. Accordingly, AmeriHealth standards require that medical records are maintained in a manner that is current, detailed, and organized as required by applicable regulatory requirements.

● Access and availability standards. AmeriHealth standards ensure that our managed care networks are adequate to meet the needs of our members with respect to location and appointment accessibility for primary and specialty care as well as urgent and emergency care in accordance with applicable regulatory requirements.

● Privacy and confidentiality. AmeriHealth, our contractors, and our affiliates are required to protect the privacy and confidentiality of our members’ personal and health information in accordance with state and federal regulatory requirements.

Please review the standards listed in this article to ensure that your office maintains the required access, documentation, and quality care expected of our network providers.

For more information about our Quality Management Program and our progress in meeting program goals, please visit our website or contact Customer Service at 1-800-275-2583 for providers in Pennsylvania and Delaware or 1-888-YOUR-AH1 (1-888-968-7241) for providers in New Jersey. Members can request the same information by calling Customer Service.

Information about our Quality Management Program and these standards can also be found in the Provider Manual for Participating Professional Providers and the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, which are available through the NaviNet® web portal. Paper copies of the manuals can be ordered by submitting an online request at www.amerihealth.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

www.amerihealth.com/qualitymanagement


QuAlity mAnAgement

Upcoming changes to the measures for the QPM score program — measurement year 2014 (NJ and DE only)The Quality Performance Measure (QPM) score program was developed by AmeriHealth HMO, Inc. for participating primary care physicians (PCP). The QPM score program evaluates quality of care based on nationally accepted standards, such as those endorsed by the National Committee for Quality Assurance (NCQA). Annually, we evaluate participating primary care practices and score them relative to their peers based on their QPM results. Practices receive notification on their percent of completed measures compared to the percent of their peers.

New measuresAs meaningful measures of quality continue to be developed and improved, the quality indicators included in the QPM score program are continuously refined. The following measures will be added to the QPM score program for measurement year 2014:

Measure Description Eligible members

Avoidance of antibiotic treatment in adults with acute bronchitis

Members 18 through 64 who were identified as having a diagnosis of acute bronchitis through claims for outpatient or emergency room (ER) visits between January 1 through December 24 of the measurement year (2014) and who were not dispensed an antibiotic prescription.

Continuously enrolled members who were at least 18 as of January 1 of the measurement year (2014) through 64 as of December 31 of the measurement year (2014), who were identified through outpatient and ER visit claims as having a diagnosis of acute bronchitis, and who were continuously enrolled for one year prior to the diagnosis date through seven days after the diagnosis date, and who meet all of the following criteria:

● no active antibiotic prescription or any new antibiotic dispensed within 30 days prior to the diagnosis date;

● no other upper respiratory or other infectious disease that required antibiotics within 30 days prior to the diagnosis date through seven days after the diagnosis date;

● none of the following comorbid conditions in the 12 months prior to the diagnosis date:

– bronchiectasis – chronic bronchitis – COPD – cystic fibrosis – emphysema – extrinsic allergic alveolitis – HIV disease – HIV, asymptomatic – immunity disorders – malignant neoplasms – other respiratory system diseases – pneumoconiosis and other lung disease due to external agent

– tuberculosis



QuAlity mAnAgement

Upcoming changes to the measures for the QPM score program — measurement year 2014 (NJ and DE only) (continued)


Appropriate treatment for children with URI

Members 3 months through 18 who were identified through claims for outpatient or ER visits as having a diagnosis only of upper respiratory infection (URI), on or between July 1 of the year prior to the measurement year (2013) and June 30 of the measurement year (2014) and who were not dispensed an antibiotic prescription.

Continuously enrolled members who were 3 months as of July 1 of the year prior to the measurement year (2013) through 18 as of June 30 of the measurement year (2014), who were identified through outpatient or ER visit claims as having a diagnosis of URI, and who were continuously enrolled from 30 days prior to the diagnosis date through three days after the diagnosis date, and who met the following criteria:

● no diagnosis other than URI on the diagnosis date;

● no active antibiotic prescription or any new antibiotic dispensed within 30 days prior to the diagnosis date;

● no claims/encounters with the following “competing diagnoses” either on the URI diagnosis date or the three days following:

– acne – acute lymphadenitis – acute pharyngitis – acute sinusitis – acute tonsillitis – bacterial infection, unspecified – cellulitis, mastoiditis, other bone infection – chlamydia – chronic sinusitis – cystitis or UTI – gonococcal infections and VD – impetigo – infection of the kidneys – infection of the pharynx, larynx, tonsils, or adenoids

– inflammatory diseases (female reproductive organs)

– intestinal infection – lyme disease or other arthropod-borne disease – otitis media – pertussis – pneumonia – prostatitis – skin staph infection – syphilis



QuAlity mAnAgement

Upcoming changes to the measures for the QPM score program — measurement year 2014 (NJ and DE only) (continued)


Appropriate testing for children with pharyngitis

Members 2 through 18 who were identified as having a diagnosis of pharyngitis through claims for outpatient or ER visits on or between July 1 of the year prior to the measurement year (2013) and June 30 of the measurement year (2014), who were dispensed an antibiotic, and who received a group A streptococcus (strep) test for the episode within the seven day period from three days prior to the diagnosis date through three days after the diagnosis date.

Continuously enrolled members who were 2 as of July 1 of the year prior to the measurement year (2013) through 18 as of June 30 of the measurement year (2014), who were identified through outpatient or ER visit claims as having a diagnosis of pharyngitis, and who were continuously enrolled from 30 days prior to the diagnosis date, through three days after the diagnosis date, and who met the following criteria:

● no diagnosis other than pharyngitis on the diagnosis date;

● prescribed an antibiotic for the pharyngitis episode on or within three days after the diagnosis date;

● no active antibiotic prescription or any new antibiotic dispensed within 30 days prior to the diagnosis date.

Updated measuresFor measurement year 2014, the following measures are being updated:

● Breast Cancer Screening. The age range was changed from ages 42 through 69 to ages 50 through 74.

● Cervical Cancer Screening. The lower age limit was lowered from age 24 to age 21. In addition, a new requirement was added for cervical cytology/human papilomavirus co-testing.

● Cholesterol management (LDL-C) for patients with cardiovascular conditions. Credit will be given for this measure for members with LDL-C levels < 100 mg/dl.

● Diabetic care. Credit will be given for this measure for members with LDL-C levels < 100 mg/dl, as well as members with a HbA1c < 8.0%.

If you have any questions about the measure changes or the QPM score program, please contact your Network Coordinator.


heAlth And Wellness

Help your older adult patients understand the connections among depression, sleep, and exerciseAccording to the Centers for Disease Control and Prevention (CDC), older adults in the United States are at increased risk for depression, possibly due to the fact that depression is more common in people who also have other illnesses or limited function. Health care providers and sometimes older adults themselves may mistake symptoms of depression as a natural reaction to illness or life changes that tend to occur with age, and the individuals may not realize they could feel better with appropriate treatment.1

Symptoms of depression that may not be recognized immediately are unusual sleep patterns — insomnia, early-morning wakefulness, or excessive sleeping. While other health conditions or some medications may cause sleep disorders, insufficient sleep is associated with the onset of depression and also poses important implications for its management and outcome.2 Managing depression may result in healthier sleep habits, and getting appropriate amounts of quality sleep may help prevent or manage symptoms of depression.

Individuals may be able to both manage depressive symptoms and improve poor sleep through regular physical activity. Research shows that regular exercise positively affects mental health by releasing more endorphins (“feel good” neurotransmitters), reducing the risk of depression and creating a better mood.3 Regular activity also improves energy levels. While it may seem counter-intuitive to individuals’ ability to sleep better, studies have shown that activity actually helps reduce fatigue and promotes better sleep.4

SilverSneakers® can help There’s good news for your AmeriHealth Medicare-eligible patients: The Healthways SilverSneakers® Fitness Program provides them opportunities to get the physical activity they need to help combat depression and promote healthy sleep habits. In addition, the program is provided for them at no cost as part of their health plan benefits.

SilverSneakers includes:

● a fitness membership with use of all basic amenities;

● access to more than 11,000 participating locations across the nation;

● SilverSneakers group exercise classes;

● location lookup and replacement ID card ordering at www.silversneakers.com;

● SilverSneakers FLEX, which offers classes and activities at parks, recreation centers, churches, and other local venues, for opportunities outside the traditional “gym” setting.

Enrollment is fast and easy Recommend SilverSneakers today as a resource for your older adult patients who may struggle with depression and/or sleep issues. SilverSneakers offers three easy ways to enroll:

● In person. To enroll in the program, members can simply bring their SilverSneakers ID card to any participating SilverSneakers location. Members can visit the SilverSneakers website or call 1-888-423-4632 for a complete list of locations and/or request a replacement card.

● Online. Eligible members can enroll online at www.silversneakers.com/member. Enrollment gives members access to several resources, including health improvement plans and video demonstrations.

● SilverSneakers Steps. Enroll in a personalized fitness program that is designed for members who do not have convenient access to a SilverSneakers location. It offers a tool kit and “how-to” materials to help members get fit. Members can call 1-888-423-4632 (TTY: 711) for more information.

Note: SilverSneakers is offered to AmeriHealth 65® NJ HMO and AmeriHealth 65® Preferred HMO members at no cost. For more information on the program, members can visit www.silversneakers.com or call 1-888-423-4632 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m., EST.

1http://cdc.gov/aging/mentalhealth/depression.htm2http://cdc.gov/sleep3Strawbridge, W.J., Deleger, S., Roberts, R.E., & Kaplan, G.A. (2002). Physical activity reduces the risk of subsequent depression for older adults. American Journal of Epidemiology, 156(4), 328-334. Rethorst, C.D., Wipfli, B.M., & Landers, D.M. (2009). The antidepressive effects of exercise: A meta-analysis of randomized trials. Sports Medicine, 39(6), 491-511. Ruscheweyh, R., Willemer, C., Kruger, K., Duning, T., Warnecke, T., Sommer, J., Volker, K., Ho, H.V., Mooren, F., & Knecht, S. (2011). Physical activity and memory functions: An interventional study. Neurobiology of Aging, 32(7), 1304-1319.4Puetz, T.W. (2006). Physical activity and feelings of energy and fatigue: Epidemiological evidence. Sports Medicine, 36(9), 767-780. University of Georgia. “Regular Exercise Plays a Consistent and Significant Role in Reducing Fatigue.” ScienceDaily, November 1, 2006. Web. April 20, 2012.

SilverSneakers is a registered mark of Healthways, Inc.

http://cdc.gov/aging/mentalhealth/depression.htm

http://cdc.gov/sleep

I m p o r t a n t r e s o u r c e s

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*The Provider Automated System will be phased out for AmeriHealth Pennsylvania members as they are migrated to our new operating platform. Go to www.amerihealth.com/pnc/upcomingchanges for more information.

www.amerihealth.com/providerautomatedsystem

www.amerihealth.com/providersupplyline

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1-888-YOUR-AH1 (968-7241) (NJ only)

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