updateSM

New Provider Automated System is now live page 3

New Primary Health Coach model for AmeriHealth New Jersey commercial members now in effect page 12

Updated payer ID grids now available page 6

January 2016

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2015 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 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

AmeriHealth HMO, Inc., AmeriHealth Insurance Company of New Jersey.

Partners in Health UpdateSM is a publication of AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (AmeriHealth) created to provide valuable information to the AmeriHealth-participating provider community that provides Covered Services to AmeriHealth members. 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

providercommunications@amerihealth.com

Inside this edition

► Articles designated with a blue arrow include notice of changes orclarifications to administrative policies and procedures.

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

Professional Facility Ancillary

AmeriHealth 65® NJ HMO has an accreditation status of Excellent from the National Committee for Quality Assurance (NCQA).

AmeriHealth HMO, Inc. has an accreditation status of Accredited from the NCQA.

Administrative► New Provider Automated System is now live► Importance of providing timely clinical information on

emergency admissions► Concierge medical practices prohibited as a participating

provider► 2015 Cumulative Index now available● Update your provider information with us► Confirmation of precertified procedures

Billing► Updated payer ID grids now available► Upcoming changes to claims reporting requirements for home

infusion providers

Medical● Reminder: Changes to precertification requirements for 2016► Precertification changes for AmeriHealth Pennsylvania

non-emergent outpatient radiation therapy services► AmeriHealth New Jersey non-emergent outpatient radiation

therapy precertification requirements now in effect► View up-to-date policy activity on our Medical Policy Portal

NaviNet®

● Reminder: NaviNet® resources available

Pharmacy► Tips to promote antimicrobial stewardship in our community► Prescribing high-risk medications for your older adult patients

Quality Management● Ensure patients know how to access care after office hours

Health and Wellness● New Primary Health Coach model for AmeriHealth New Jersey

commercial members now in effect

ADMINISTRATIVE

January 2016 | Partners in Health UpdateSM 3 www.amerihealth.com

New Provider Automated System is now liveDuring December, AmeriHealth launched a new Provider Automated System to help providers obtain critical information.

When you call 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or 1-800-275-2583 for AmeriHealth Pennsylvania, be sure to say “Provider” or press 2 when prompted.

Once in the Provider Automated System, you will need to have your National Provider Identifier (NPI) or tax ID number, as well as the member’s information (member ID number and date of birth), ready in order to access the information below.

The Provider Automated System enables providers to retrieve the following information by following a series of self-service voice prompts and questions specific to your inquiry:

● Eligibility. Check coverage status, effective dates, and group name information. ● Benefits.* Verify copayment, coinsurance, and deductible information. ● Claims. Obtain paid status, claim denial reasons, paid amount, and member responsibility information.

For authorizations you should enter and retrieve information through the NaviNet® web portal.

User guide A user guide for the new Provider Automated System is available on our websites at www.amerihealthnj.com/html/providers/tools_resources for AmeriHealth New Jersey and at www.amerihealth.com/providerautomatedsystem for AmeriHealth Pennsylvania. Look for additional information in future editions of Partners in Health Update.

*The benefits function is coming soon for AmeriHealth New Jersey members.

Importance of providing timely clinical information on emergency admissionsIn order to efficiently conduct admission reviews of inpatient emergency admissions, clinical information regarding the member’s medical condition and treatment is required. Clinical information should be provided within a short time frame after notification of emergency admissions. Ideally, this information should be sent to AmeriHealth within two business days. Failure to provide the required information within 30 days of notification of admission will result in case closure with a denial due to lack of information.

Should the hospital receive a denial due to lack of information, the request for an admission review can be resubmitted when the clinical information is available. To submit the new request, call 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or 1-800-275-2583 for AmeriHealth Pennsylvania and follow the prompts for authorizations. Please note that the submission of complete medical records is not required and could delay the admission review process.

For questions regarding this information, please contact Alfreda Earp, administrative assistant, at 215-241-3065, and she will direct your inquiry to the appropriate area.

ADMINISTRATIVE

January 2016 | Partners in Health UpdateSM 4 www.amerihealth.com

Concierge medical practices prohibited as a participating providerConcierge medicine, also referred to as retainer medicine, is a relationship between a patient and a physician in which the patient pays an annual fee or retainer. Please be advised that the practice of charging AmeriHealth members a mandatory annual payment violates the terms of your AmeriHealth Professional Provider Agreement (“Agreement”).

Physicians who participate with AmeriHealth are required to comply with the terms and conditions of their Agreement, which requires participating providers to accept payment from AmeriHealth as payment in full for Covered Services. Covered Services are considered to include:● well-patient visits● emergency telephone consultation available 24 hours a day, seven days a week● treatment of acute conditions● coordination of medically necessary care● referrals to appropriate specialists for treatment

In addition, extending the length of a visit, coordinating medically necessary care, and/or providing wellness-type services are integral to the provision of Covered Services and are consistent with a standard of care AmeriHealth expects from participating providers.

Participating providers are required to provide Covered Services during normal business hours, but they must also be available to AmeriHealth members by telephone 24 hours a day, seven days a week, for consultation on medical concerns and emergencies.

Please be advised that AmeriHealth-participating providers who elect to open a concierge practice that requires members to pay a designated fee for Covered Services to remain in their practice are in violation of their Agreement and are subject to termination from the AmeriHealth network.

If you have any questions, please contact your Network Coordinator or Provider Partnership Associate.

2015 Cumulative Index now available The 2015 Provider Publication Cumulative Index (2015 Cumulative Index) is included with this edition of Partners in Health Update. This index lists all of the 2015 articles that were published in Partners in Health Update, the edition in which they can be found, and the provider audience type for which the article was intended.

A complete archive of all cumulative indexes is also available by selecting Cumulative Index in the Quick Links section of our Provider News Center at www.amerihealth.com/pnc.

Printed copies of the 2015 Cumulative Index can be ordered by submitting an online request at www.amerihealth.com/providersuppplyline or by calling the Provider Supply Line at 1-800-858-4728.

ADMINISTRATIVE

January 2016 | Partners in Health UpdateSM 5 www.amerihealth.com

Update your provider information with usHave you made any changes to your key provider information? It is important that you notify us of any changes to the following:

● your mailing address ● name of your practice ● your phone number ● your acceptance of new patients ● your office hours ● your plan to dissolve your practice

We value your help in keeping our data files current. Accurate data files allow us to provide you with important information on billing, claims, changes or additions to policies, and announcements of administrative processes.

Professional providers Please contact your Provider Partnership Associate or Network Coordinator and notify them of any changes to your information.

Facility and ancillary providers Per your contract, you are required to submit any changes to your information in writing. This request should be sent directly to the Legal Department and the appropriate Provider Network contact at the addresses below:

AmeriHealth Attn: Legal Department 1901 Market Street, 43rd Floor Philadelphia, PA 19103

AmeriHealth New Jersey Attn: Vice President, Provider Network Operations 259 Prospect Plains Road, Building M Cranbury, NJ 08512

AmeriHealth Attn: Senior Vice President, Provider Networks and Value-Based Solutions 1901 Market Street, 27th Floor Philadelphia, PA 19103

Sixty days’ advance notice is required for processing.

Note: This information does not apply to providers contracted with Magellan Healthcare, Inc. Please contact your Magellan Network Coordinator, if you have any questions.

Confirmation of precertified proceduresApprovals for inpatient elective admissions are based on procedures that require an inpatient level of care. There are times when procedures are precertified but never performed due to various reasons. In such cases, AmeriHealth is responsible for assessing whether the inpatient admission is still medically appropriate. Therefore, we are required to confirm if the precertified procedures were actually performed, and if not, to validate the medical necessity of the admission.

If we are unable to confirm the procedures, the original authorization request will remain open and payment will not be made. The Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, which is available in the Current Publications section of AmeriHealth NaviNet® Plan Central, is being updated to reflect this process.

BILLING

January 2016 | Partners in Health UpdateSM 6 www.amerihealth.com

Upcoming changes to claims reporting requirements for home infusion providers Effective March 1, 2016, AmeriHealth will adopt new claims reporting requirements for drugs obtained from in-network home infusion providers. The following information will be required when submitting all home infusion drug claims:

● NDC. The specific National Drug Code (NDC) that corresponds to the drug formulation administered to the member must be reported.

● HCPCS or CPT® codes. The specific Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) code for the drug must be reported. Exception: For drugs without a specific HCPCS or CPT code, report the J3490 or J3590 not otherwise classified (NOC) code, as appropriate.

● Units of drug administered. Drug units must be reported in multiples of the dosage unit specified in the HCPCS/CPT code narrative. Exception: For drugs without a specific HCPCS or CPT code, report the units in multiples of the drug units specified in the NDC.

Failure to include these components in a claim may result in delayed processing and reimbursement.

Note: Precertification requests submitted through the NaviNet® web portal will continue to follow the same submission process that is in effect today.

For more informationThe following claim payment policies are being updated to address these new billing requirements and provide specific claims examples:

● Commercial: #00.01.49b: Reporting Requirements for Drugs and Biologics ● Medicare Advantage: #MA00.024a: Reporting Requirements for Drugs and Biologics

View the Notifications for these policies by visiting our Medical Policy Portal at www.amerihealth.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select Commercial or Medicare Advantage under Active Notifications.

We ask that you review these policies in their entirety and share them with your staff so they can become familiar with the new requirements prior to March 1, 2016.

Updated payer ID grids now available The professional and facility payer ID grids contain valuable information to assist you in claims submission, including alpha prefixes, payer information, and claims mailing addresses by product. They have recently been updated to reflect new products for 2016.

The updated versions are available at: ● AmeriHealth New Jersey. Go to the Provider Forms web page at www.amerihealthnj.com/html/providers/

provider_forms.html. Under Claims Requirements and Communications, select either Facility Payer ID Provider Number Reference or Professional Payer ID Provider Number Reference.

● AmeriHealth Pennsylvania. Go to the Electronic Data Interchange (EDI) web page at www.amerihealth.com/edi. Under EDI Resources, select either Facility Payer ID or Professional Payer ID.

MEDICAL

January 2016 | Partners in Health UpdateSM 7 www.amerihealth.com

Reminder: Changes to precertification requirements for 2016 As a reminder, in 2016 new precertification requirements will apply to our commercial HMO and PPO and Medicare Advantage HMO members for the following service and drugs.

Service Bronchial thermoplasty will require precertification approval from AmeriHealth in 2016 as follows:

● Effective January 1, 2016, precertification will be required for members enrolled in Medicare Advantage plans. ● Effective March 1, 2016, precertification will be required for members enrolled in commercial plans.

Drugs As of January 1, 2016, the medical benefit drugs listed below will require precertification approval from AmeriHealth:

● Adagen® (pegademase bovine) ● Kanuma™ (sebelipase alfa) ● Blincyto® (blinatumomab) ● Lemtrada® (alemtuzumab) ● Cyramza® (ramucirumab) ● Nucala® (mepolizumab) ● Gel-Syn™ (sodium hyaluronate)* ● VISCO-3™ (sodium hyaluronate)* ● GenVisc 850® (sodium hyaluronate)* ● Zevalin® (ibritumomab tiuxetan)†

● Imlygic™ (talimogene laherparepvec)

These changes are reflected in updated precertification requirement lists, which are available at www.amerihealthnj.com/html/providers/policies.html for AmeriHealth New Jersey and at www.amerihealth.com/ preapproval for AmeriHealth Pennsylvania.

* This drug requires precertification approval as of January 1, 2016 for AmeriHealth Pennsylvania members, and as of March 1, 2016, for AmeriHealth New Jersey members.

† Precertification review for this drug is currently provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).

Precertification changes for AmeriHealth Pennsylvania non-emergent outpatient radiation therapy services As previously communicated, providers are required to obtain precertification through CareCore National, LLC d/b/a eviCore healthcare (eviCore) for non-emergent outpatient radiation therapy services for all commercial HMO and POS members.

Effective January 1, 2016, the list of radiation therapy procedure codes that require precertification has been updated. Medical Policy #09.00.56b: Radiation Therapy Services includes an updated list of procedure codes that require precertification as well as a link to the criteria that eviCore will use to determine medical necessity for radiation therapy services.

To view this policy, visit our Medical Policy Portal at www.amerihealth.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial tab from the top of the page. Type the policy name or number in the Search field.

Requesting precertificationYou can initiate precertification for non-emergent outpatient radiation therapy in one of the following ways:

● NaviNet® web portal. Select eviCore/CareCore from the Authorizations option in the AmeriHealth Workflows menu.

● Telephone. Call eviCore directly at 1-866-686-2649.

MEDICAL

January 2016 | Partners in Health UpdateSM 8 www.amerihealth.com

AmeriHealth New Jersey non-emergent outpatient radiation therapy precertification requirements now in effect As of January 1, 2016, precertification for non-emergent outpatient radiation therapy services for all commercial and Medicare Advantage AmeriHealth New Jersey members is required. AmeriHealth New Jersey is working with CareCore National, LLC d/b/a eviCore healthcare (eviCore), a specialty benefit management company, to manage precertification requests for non-emergent outpatient radiation therapy services.

Services that require precertification Ordering physicians must contact eviCore to obtain precertification for elective, non-emergent outpatient radiation therapy services. Below is a list of radiation therapy services that require precertification*:

● external beam, including 2D, 3D conformal, intensity-modulated radiation therapy (IMRT), tomotherapy, image-guided radiation therapy (IGRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS);

● proton beam radiation therapy; ● brachytherapy, including low-dose rate (LDR),

high-dose rate (HDR), and outpatient intra-operative techniques (IORT);

● hyperthermia; ● neutron radiotherapy; ● radio-labeled drugs used for radiation therapy

(e.g., Radium Ra 223 dichloride [Xofigo®], ibritumomab tiuxetan [Zevalin®]).

Please note that for members under the age of 19, services requested will be automatically approved; however, precertification through eviCore is still required to ensure accurate and timely claims payment.

As a reminder, precertification requests for all high-technology diagnostic imaging services (e.g., CT, MRI, PET) continue to be handled through the current process by AIM Specialty Health®.

Precertification guidelines The AmeriHealth criteria used as the basis for reviewing precertification requests are available on eviCore’s website at www.carecorenational.com/ benefits-management/radiation-therapy/radiation- therapy-tools-and-criteria.aspx.

In addition, the following medical policies include a link to the criteria that eviCore uses to determine medical necessity for radiation therapy services as

well as a complete list of procedure codes that require precertification:

● Commercial: #09.00.56b: Radiation Therapy Services; ● Medicare Advantage: #MA09.020b: Radiation

Therapy Services.

To view these policies, visit our Medical Policy Portal at www.amerihealth.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you’d like to view, and then type the policy name or number in the Search field.

Requesting precertification Use the NaviNet® web portal to initiate precertification for non-emergent outpatient radiation therapy. Select eviCore/CareCore from the Authorizations option in the Workflows menu, and a new window will open that sends providers directly to eviCore’s provider portal and initiates the precertification process. Once on eviCore’s portal, you will be required to create a login and password. This login will be used every time you request precertification through eviCore. If you have already established credentials for eviCore’s portal, please use your current login information.

You can also request precertification by calling eviCore directly at 1-866-686-2649.

For more information If you have questions about these new precertification requirements, contact your Provider Partnership Associate, call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241), or call eviCore at 1-866-686-2649.

* This list of services is subject to change. Be sure to verify precertification requirements at the time of service.

Additional training sessioneviCore will host the following tutorial webinar to assist you in using their portal to request precertification for non-emergent outpatient radiation therapy services:

● Wednesday, January 20, 2016, at 2 p.m.

If you are interested in participating, email your contact information to providercommunications@amerihealth.com.

MEDICAL

January 2016 | Partners in Health UpdateSM 9 www.amerihealth.com

View up-to-date policy activity on our Medical Policy Portal Changes to AmeriHealth medical and claim payment policies for our commercial and Medicare Advantage Benefits Programs occur frequently in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity section of our Medical Policy Portal in order to keep up to date with changes to our policies.

The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics include:

● Notifications ● Reissued Policies ● New Policies ● Coding Updates ● Updated Policies ● Archived Policies

For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference.

To access the Site Activity section, go to our Medical Policy Portal at www.amerihealth.com/medpolicy and select Accept and Go to Medical Policy Online. From here you can select Commercial or Medicare Advantage under Site Activity to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage tab from the top of the page. You can also get to our Medical Policy Portal through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

Reminder: NaviNet® resources available As previously communicated, AmeriHealth has instituted a number of provider self-service requirements under which providers must use the NaviNet web portal to obtain certain information. Therefore, all participating providers, facilities, Magellan-contracted providers, and billing agencies that support provider organizations are required to have NaviNet access.

Over the past several years, we have been making updates and enhancing AmeriHealth NaviNet Plan Central to provide the best tool possible for our provider network. Given the significant number of changes, we created a repository on our Provider News Center to house all NaviNet-related information we publish. The NaviNet Resources page is available at www.amerihealth.com/pnc/navinet and includes dozens of transaction-specific user guides and instructional webinars, as well as a communication archive of articles published in Partners in Health Update about NaviNet changes.

If you have any questions about NaviNet transactions or you would like training for your office, please call our eBusiness Hotline at 609-662-2565 for AmeriHealth New Jersey or at 215-640-7410 for AmeriHealth Pennsylvania. If you are not yet NaviNet-enabled, go to the NaviNet website at www.navinet.net to sign up.

NAVINET®

News & AnnouncementsIn addition to the information posted in our Site Activity section, articles related to our website and medical and claim payment policies are periodically posted within the News & Announcements section. Simply select the appropriate link (Commercial or Medicare Advantage) under the News & Announcements header on the Medical Policy Portal homepage to stay informed of the latest information.

PHARMACY

January 2016 | Partners in Health UpdateSM 10 www.amerihealth.com

Prescribing high-risk medications for your older adult patients In the December 2015 edition of Partners in Health Update, we provided information about high-risk medications (HRM) and the increased potential for side effects in adults ages 65 and older. In this edition, we want to remind you that prior authorization may be required for some HRMs.

Initially derived from the American Geriatric Society’s “Beer’s Criteria,” HRMs have been proven to put older patients at a higher risk for adverse drug events. For example, medications such as zolpidem, amitriptyline, estrogens, and glyburide place patients at a higher risk for drug-related toxicities and increased risk for falls and fractures.

The National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services continue to monitor utilization of medications considered to be high-risk in older adults. Careful and appropriate use of drugs in the senior population is a critical quality-of-care issue. For these reasons, we suggest that you use caution when prescribing one or more drugs on the HRM list to patients ages 65 and older.

Go to www.pqaalliance.org/images/uploads/files/HRM2015.pdf to view the complete list of HRMs.

Prior authorization requirementBased on the risks of some HRMs, you may encounter the need to obtain prior authorization. Review the FutureScripts® Select Drug Formulary Guide at www.futurescripts.com/FutureScripts/for_health_care_professionals/prior_authorization/prior_auth_commercial.html to determine which HRMs require prior authorization (i.e., those with “PA” indicated in the Additional Requirements column).

If the medication requires prior authorization, you can obtain the proper form at www.futurescripts.com/FutureScripts/for_health_care_professionals/prior_authorization.

Tips to promote antimicrobial stewardship in our communityThe Infectious Diseases Society of America (IDSA) defines antimicrobial stewardship as the “coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.”1 These efforts seek to improve clinical outcomes, reduce health care costs, and slow bacterial resistance rates.

The following tips can help to promote antimicrobial stewardship:

● Consider practicing “watchful waiting” for upper respiratory infections in children and acute bronchitis in adults. Examples include:

− The 3-Day Rule: Follow up with patients three days after the initial visit to discuss treatment options if symptom relief has not occurred.

− The Poster Board Pledge: Display a poster-sized commitment letter in exam rooms to avoid inappropriate antibiotic prescribing. Recent studies show this as a simple, low-cost, and effective method for improvement.2

● Order group A streptococcus tests in children with pharyngitis prior to ordering antibiotics as “only about 30 percent of all cases of pharyngitis in children are caused by bacteria. Be sure to follow the pediatric guidelines for appropriate treatment.”3

● Minimize the use of broad-spectrum antibiotics when narrow-spectrum antibiotics are indicated and recommended.

To learn more about the IDSA’s efforts to promote antimicrobial stewardship in human medicine, visit their website at www.idsociety.org/Stewardship_Policy.

1 http://www.idsociety.org/Stewardship_Policy/ and http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/

2 Meeker D, et al. “Nudging guideline-concordant antibiotic prescribing: A randomized clinical trial,” JAMA Intern Med. 2014;174(3):425-31

3 National Committee for Quality Assurance (NCQA). The State of Health Care Quality 2014. Washington (DC): National Committee for Quality Assurance (NCQA); Final Edition 2014; p. 70

QUALITY MANAGEMENT

January 2016 | Partners in Health UpdateSM 11 www.amerihealth.com

Ensure patients know how to access care after office hoursPrimary and specialty care physicians make it a practice to provide coverage after office hours and on weekends. In fact, it is a requirement for all network providers to maintain this coverage. However, are your patients aware of this service, or are they simply going to the emergency room/department (ER) for care?

Recent findingsAccording to the 2014 Accessibility of Services Report, over the last three years the number of members enrolled in AmeriHealth New Jersey HMO plans who called their physician after office hours remained essentially unchanged. (Comparison data is unavailable for members enrolled in AmeriHealth New Jersey PPO plans or AmeriHealth Pennsylvania plans due to changes in data collection for 2014 reporting purposes.)

Another recent study of a targeted member population showed that members were utilizing the ER for urgent medical care, including otitis media, upper respiratory infection, and acute pharyngitis. Thirty four percent of these ER visits occurred on the weekend, when most primary care practices are closed. Although some providers have voicemail or answering services that answer calls after hours, this may not prevent an ER visit if:

● the patient does not call; ● there is a delay in physician response; ● the member/caregiver does not understand the

difference between an emergency and urgent medical care need.

Visits to the ER can interrupt continuity of care and may affect quality of care as well — especially if the patient’s physician is unaware of the ER visit and needed follow-up care is absent.

Educate your patients AmeriHealth encourages all physicians to discuss after-hours and weekend coverage, as well as the availability of urgent care centers and retail health clinics with their patients. Physicians can communicate this message by:

● placing a notification in the office that explains how to contact you when the office is closed;

● providing a listing of the nearest urgent care centers and retail health clinics;

● discussing coverage individually with patients.

Remind patients to contact their primary physician or specialist after a visit to the ER, urgent care center, or retail health clinic for assessment of appropriate follow-up care. This is especially important for pediatric patients, elderly patients, and those patients with chronic conditions. Explain that calling will allow the physician office to coordinate services with the facility for the best patient outcome.

All patients want to receive the best possible care, so if they understand the rationale behind the request, they may be more apt to communicate more openly with your office to coordinate care after hours and after visits to the ER, urgent care center, or retail health clinic.

HEALTH AND WELLNESS

January 2016 | Partners in Health UpdateSM 12 www.amerihealth.com

New Primary Health Coach model for AmeriHealth New Jersey commercial members now in effectAs of January 1, 2016, AmeriHealth New Jersey commercial members have been transitioned to the Primary Health Coach model, consistent with all other AmeriHealth members. The Primary Health Coach model gives members a single point of contact for all issues and concerns related to disease/condition and case management (this combination is called care management).

The following table describes the programs now available to AmeriHealth New Jersey commercial members:

Program Program description

Disease/condition management Offers eligible members 24/7/365 access to a Health Coach by calling 1-888-YOUR-AH1 (1-888-968-7241)

Case management Provides members with extra support when dealing with an acute illness, chronic condition, or multiple comorbidities

Benefits of the Primary Health Coach model include: ● The Health Coach remains consistent as a member transitions across the health care continuum. This

consistency ensures patient-centered coaching that is individualized and coordinated. ● The Health Coach and member can develop a trusted relationship, which fosters higher levels of member

engagement and helps members reach their health goals. ● A Health Coach has a 360-degree view of a member’s complete health record using an integrated nurse

dashboard, which puts information at the Health Coach’s fingertips. This display features information about the member’s condition, prescription drugs, recent diagnostic or therapeutic activities, and patterns of treatment and procedures. Such complete data review allows our Health Coaches to have a more meaningful interaction with a member and improves the customer experience.

What providers need to knowProviders should now refer all AmeriHealth New Jersey members for case and condition management by submitting an online physician referral form at www.amerihealthnj.com/html/providers/case_management.html. Providers who wish to refer their patients by telephone should call 1-800-313-8628.

What members need to knowAmeriHealth New Jersey members should continue to call the same number (1-888-YOUR-AH1) to reach a Health Coach. Once they indicate that they would like to speak to a Health Coach, their call will be routed to a Health Coach at AmeriHealth. Members have 24/7/365 access to a Health Coach and online educational tools.

If you or one of your AmeriHealth New Jersey patients has any questions, please call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241).

Visit our Provider News Center: www.amerihealth.com/pnc

Important Resources

Anti-Fraud and Corporate Compliance

Hotline www.amerihealth.com/antifraud | 1-866-282-2707

Care Management and Coordination

Baby FootSteps® 1-800-598-BABY (2229)

Case and Condition Management 1-800-313-8628

Credentialing

Credentialing Violation Hotline www.amerihealth.com/credentials | 215-988-1413

Credentialing and recredentialing inquiries 1-866-227-2186 (NJ only)

Customer Service/Provider Services

Provider Services NJ: 1-888-YOUR-AH1 (968-7241); PA: 1-800-275-2583

Electronic Data Interchange (EDI)

Highmark EDI Operations 1-800-992-0246

FutureScripts® (commercial pharmacy benefits)

Pharmacy benefits 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.amerihealth.com/rx

FutureScripts® Secure (Medicare Part D pharmacy benefits)

FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.amerihealthmedicare.com

Imaging services

CT, MRI/MRA, PET, and nuclear cardiology NJ: 1-800-859-5288; PA: 1-800-275-2583

NaviNet® web portal

AmeriHealth eBusiness Hotline NJ: 609-662-2565; PA: 215-640-7410

Registration www.navinet.net

Other frequently used websites and phone numbers

AmeriHealth Direct Ship Drug Program (medical benefits) www.amerihealth.com/directship

Medical Policy www.amerihealth.com/medpolicy

Provider Supply Line www.amerihealth.com/providersupplyline | 1-800-858-4728

Provider RemittanceHow to read your Facility Provider RemittanceAncillary Providers: Refer to this guide only when working with Facility providers.

2015 Provider Publication Cumulative IndexThis index captures articles that were published in 2015 in Partners in Health UpdateSM . Partners in Health Update includes notice of changes or clarifications to administrative policies and procedures that are related to the covered services provided by AmeriHealth-participating providers.

AmeriHealth HMO, Inc. | AmeriHealth Insurance Company of New Jersey

2015 Provider Publication Cumulative Index

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Table of Contents

Partners in Health UpdateAdministrative ......................................................................................................................3Announcements ...................................................................................................................4Billing ...................................................................................................................................4Consumerism.......................................................................................................................5Credentialing........................................................................................................................5Health and Wellness ............................................................................................................5ICD-10 .................................................................................................................................6Medical ................................................................................................................................7NaviNet® ..............................................................................................................................8Pharmacy.............................................................................................................................9Products...............................................................................................................................9Quality Management..........................................................................................................10

Note: Partners in Health Update articles are specific to a provider type. The audience is identified by the following indicators:

P – ProfessionalF – FacilityA – Ancillary

NaviNet is a registered trademark of NaviNet, Inc.

SilverSneakers is a registered mark of Healthways, Inc.

CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Partners in Health Update

AdministrativeArticle title Edition Audience

2014 Cumulative Index now available January P, F, A

All AmeriHealth New Jersey Medicare Advantage HMO members migrated to the new platform January P, F, A

Reminder: AmeriHealth New Jersey introduces Community Advantage, adding two South Jersey hospitals January P, F, A

Stay informed during our transition to the new platform February P, F, A

Updated time frame for processing PCP changes February P

Stay informed during our transition to the new platform March P, F, A

Updated AmeriHealth New Jersey Provider Manual now available March P

AmeriHealth Pennsylvania platform transition has been completed April P, F, A

Changing the way we do business for AmeriHealth New Jersey members April P, F, A

Updated AmeriHealth Pennsylvania Provider Manual now available April P

Overpayments for certain Medicare Advantage members identified and corrected May P, A

Provider Automated System no longer available for migrated members May P, F, A

Report prescription drug or health care fraud May P, F, A

Coming soon: Easy to use online peer-to-peer request form June P, F, A

Help prevent identity theft and insurance fraud June P, F, A

Reminder: Provider Automated System no longer available for migrated members June P, F, A

Medicare Advantage members must use designated site for capitated services July P

New name – same great service (NJ only) July P, F, A

Procedures for terminating a patient from a practice July P

Referring members for laboratory services August P

Re-issue of member ID cards for AmeriHealth New Jersey commercial members upon migration August P, F, A

Reminder from AmeriHealth Administrators: Register on NaviNet® August P, F, A

Reminder: Provider Automated System not available for migrated AmeriHealth New Jersey members August P, F, A

Upcoming changes to claims processing requirements and enforcing these changes for AmeriHealth New Jersey members August P, F, A

An updated provider appeals form now available September P, F

Interpreting your PCP payments via EFT September P

Migration of AmeriHealth New Jersey commercial members begins September 1, 2015 September P, F, A

Reminder: Medicare Advantage members must use designated site for capitated services September P

Carenet pilot program underway October P

Chronic care management for Medicare beneficiaries October P

Coming soon: New Provider Automated System October P, F, A

Peer-to-peer reconsideration requests for Medicare Advantage members October P, F, A

Reminder: Migration of AmeriHealth New Jersey commercial members October P, F, A

Update your provider information with us October P, F, A

4

Partners in Health Update

AnnouncementsArticle title Edition Audience

Discontinuation of postcard notification for Partners in Health Update August P, F, A

BillingArticle title Edition Audience

Modifier 25 required for reporting removal of impacted cerumen January P, F, A

Updated payer ID grids available soon January P, F, A

Additional HIPPS code requirements for certain SNF claims/encounters February F, A

Claim submission requirements when billing with place of service code 22 March P

Important billing information for modifiers 25 and 59 March P

POA indicator and properly filling out claims March F

Professional Injectable and Vaccine Fee Schedule updates effective April 1, 2015 March P, F, A

Proper screening colonoscopy billing for Medicare Advantage members March P, F

Correction: Claim submission requirements when billing with place of service code 22 April P, A

Updated process for submitting an overpayment/refund request April P, F, A

Enforcing claims processing requirements May P, F, A

Reminder: Billing requirements for billing multiple services May P

Reminder: Important billing information for modifiers 25 and 59 May P

Professional Injectable and Vaccine Fee Schedule updates effective July 1, 2015 June P, F, A

Reminder: Transitioning outstanding Accounts Receivable balances to new platform June P, F

SOR changes for migrated AmeriHealth New Jersey members June P, F, A

Billing requirement for anesthesia claims July P

Claims processing requirements for PCPs rendering services to members in long-term care facilities July P, A

Guidelines for billing with taxonomy codes and use of NPI on claims August P, F, A

Reminder: Important billing information for modifier 25 and modifiers –X{EPSU} and 59 August P

Administrative (continued)Article title Edition Audience

Migration of AmeriHealth members has been completed November P, F, A

Update your provider information with us November P, F, A

New AmeriHealth Administrators office location December P, F, A

New Provider Automated System launch postponed December P, F, A

Out-of-pocket maximums for commercial HMO, POS, and PPO members beginning January 1, 2016 December P, F, A

Update your provider information with us December P, F, A

5

Partners in Health Update

ConsumerismArticle title Edition Audience

AmeriHealth to roll out new and improved member portal July P, F, A

CredentialingArticle title Edition Audience

Upcoming changes to the CAQH recredentialing process January P

Reminder: Changes to the CAQH recredentialing process February P

Billing procedures for credentialed Certified Registered Nurse Practitioners March P

New CAQH recredentialing process now in effect March P

Health and WellnessArticle title Edition Audience

Encourage pregnant AmeriHealth members to register for Baby FootSteps® February P

Help your Medicare Advantage patients get fit in 2015 February P

Know your terms April P

Encourage pregnant AmeriHealth members to register for Baby FootSteps May P

Help your heart failure patients avoid hospital readmission May P

Billing (continued)Article title Edition Audience

Select standard fee schedules available on NaviNet® August P, F

Updated CMS-1500 claim form resources now available August P, A

Use the full member ID number when billing for service August P, F, A

Medical Nutrition Therapy coverage for Medicare Advantage members September P

Professional Injectable and Vaccine Fee Schedule updates effective October 1, 2015 September P, F, A

Reminder: Requirements for billing multiple services October P

Reminder: Important billing information for modifiers 25 and –X{EPSU} and 59 November P

Updated UB-04 guide and CMS-1500 toolkit now available November P, F

Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2016 December P, F, A

Updated payer ID grids available soon December P, F, A

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Partners in Health Update

ICD-10Article title Edition Audience

ICD-10: External testing with providers to resume in early 2015 February P, F, A

External testing update and tips for a successful conversion April P, F, A

The AmeriHealth guidelines for submitting authorizations and referrals May P, F, A

Clarification: AmeriHealth guidelines for submitting authorizations and referrals June P, F, A

Get ready for the upcoming ICD-10 compliance date July P, F, A

ICD-10 is fast approaching – Are you ready? August P, F, A

Preparing for the upcoming October 1, 2015, ICD-10 compliance date September P, F, A

ICD-10: FAQ highlights October P, F, A

Common ICD coding errors identified on paper and electronic claims December P, F, A

Health and Wellness (continued)Article title Edition Audience

Help your patients stay fit this spring with SilverSneakers® May P

Suicide: A concern for all health care providers. Part 1 – An introduction to recognizing the role of all health care providers to address the issue of suicide May P

AmeriHealth New Jersey case managers offer extra support to members June P

Urgent care centers and retail health clinics are alternatives to the ER when physicians are unavailable June P

2015 AmeriHealth New Jersey Perinatal Guidelines now available July P

Suicide: A concern for all health care providers. Part 2 – Embracing your role through screening, assessing, and promoting safety for individuals at risk for suicide July P

Encourage pregnant AmeriHealth members to register for Baby FootSteps August P

Health Coaches: Supporting your patients, our members August P

Help your patients get healthy this summer with SilverSneakers August P

New behavioral health resources for collaboration and care August P, F

Let’s Go See initiative raises awareness of vision problems in children September P

Suicide: A concern for all health care providers. Part 3 – After screening/assessing: How to assure safety of the person who is at risk for suicide September P, F, A

New Primary Health Coach model for AmeriHealth New Jersey commercial members October P

Encourage pregnant AmeriHealth members to register for Baby FootSteps November P

Help your patients stay healthy in mind, body, and spirit throughout the holiday season with SilverSneakers November P

Suicide: A concern for all health care providers. Part 4 – Suicide risk assessment: Important issues to remember November P

Reminder: New Primary Health Coach model for AmeriHealth New Jersey commercial members December P

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Partners in Health Update

MedicalArticle title Edition Audience

Changes to the experimental/investigational services policies effective January 1, 2015 January P, F, A

Download the latest precertification requirement list January P, F, A

Injectable hyaluronate acid products being removed from the AmeriHealth Direct Ship Injectables Program January P

Medical and claim payment policy activity posted from November 21 – December 19, 2014 January P, F, A

Medicare Advantage HMO policies now in effect January P, F, A

New codes for digital breast tomosynthesis January P, F, A

Precertification requirement for non-emergent outpatient radiation therapy now in effect January P, F

Reminder: Precertification requirements for DME providers now in effect January P, A

Medical and claim payment policy activity posted from December 20, 2014 – January 23, 2015 February P, F, A

New changes to our ePASS® incentive opportunity for professional providers February P

Precertification and compliance monitoring for PAP machines and supplies February P, F, A

Clarification: Injectable hyaluronate acid products being removed from the Direct Ship Injectables Program March P

Medical and claim payment policy activity posted from January 24 – February 20, 2015 March P, F, A

Non-emergent outpatient radiation therapy to be reviewed for medical necessity March P, F

Medical and claim payment policy activity posted from February 21 – March 23, 2015 April P, F, A

NaviNet® to provide direct access link to CareCore’s provider portal April P, F

CareCore’s radiation therapy criteria now in effect May P, F

Changes to the Direct Ship Injectables Program May P

Medical and claim payment policy activity posted from March 24 – April 24, 2015 May P, F, A

Gender reassignment surgery claims for Medicare Advantage members June P, F

Medical and claim payment policy activity posted from April 25 – May 22, 2015 June P, F, A

New medical policy criteria for commercial members in treatment for osteoarthritis of the knee June P

Updated InterQual® guidelines for 2015 June P, F, A

Upcoming changes to the enforcement of medical and claim payment policy for AmeriHealth New Jersey members June P, F, A

Obtaining precertification for non-emergent radiation therapy services through NaviNet July P, F

Reminder: Upcoming changes to the medical and claim payment policy for AmeriHealth New Jersey members July P, F, A

Reminder: Use –X{EPSU} modifiers to report separate, distinct, or independent non-E&M services on the same day July P, F

View up-to-date medical and claim payment policy activity on the Medical Policy Portal July P, F, A

View up-to-date medical and claim payment policy activity on the Medical Policy Portal August P, F, A

Annual Synagis® (palivizumab) distribution program approaches September P, A

Chiropractic services policy update September P

Reminder: Coverage for injectable drugs that reduce the risk of preterm birth September P, F

View up-to-date policy activity on our Medical Policy Portal September P, F, A

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Partners in Health Update

NaviNet®

Article title Edition Audience

Changes coming in February 2015 to NaviNet January P, F, A

NaviNet changes delayed until March February P, F, A

Changes coming to NaviNet in March March P, F, A

User guides and webinar now available for recent NaviNet transaction changes April P, F, A

Changes to NaviNet Referrals transaction coming in May May P, F

NaviNet functionality will apply to New Jersey commercial members upon migration to the new platform June P, F, A

New changes to NaviNet scheduled for July release June P, F, A

Reminder of upcoming July NaviNet release July P, F, A

Changes coming in mid-September to NaviNet September P, F, A

Reminder of recent changes to NaviNet October P, F, A

Providers required to use self-service options on NaviNet November P, F, A

NaviNet resources available on the Provider News Center December P, F, A

Medical (continued)Article title Edition AudienceAmeriHealth New Jersey introduces non-emergent outpatient radiation therapy precertification requirements October P, F

Direct Ship Drug Program updates October P

Important news about the annual Synagis® (palivizumab) distribution program October P

Upcoming changes to drug precertification requirements for 2016 October P

Upcoming changes to medical benefit specialty drug cost-sharing for 2016 October P

View up-to-date policy activity on our Medical Policy Portal October P, F, A

Appropriate use of vitamin D testing November P, F, A

Reminder: Upcoming changes to drug precertification requirements for 2016 November P

View up-to-date policy activity on our Medical Policy Portal November P, F, A

AmeriHealth New Jersey medical record requests and ePASS® submissions now using EFT for payments December P, F

Introducing telemedicine primary care for our Pennsylvania commercial members December P

Reminder: Upcoming changes to medical benefit specialty drug cost-sharing for 2016 December P

Training available for upcoming AmeriHealth New Jersey non-emergent outpatient radiation therapy precertification requirements December P, F

Upcoming changes to precertification requirements for 2016 December P

Update on coverage for digital breast tomosynthesis December P

View up-to-date policy activity on our Medical Policy Portal December P, F, A

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Partners in Health Update

PharmacyArticle title Edition Audience

Things to remember when prescribing narcotic therapy January P

Prescription drug updates March P, F, A

Select Drug Program® Formulary updates March P, F, A

Appropriate use of Suboxone® June P

Ensuring better drug coverage determination outcomes for you and your patients June P

Prescription drug updates June P, F, A

Select Drug Program Formulary updates June P, F, A

New mail-order facility for your patients with FutureScripts® Secure coverage July P, F, A

Prescription drug updates September P, F, A

Select Drug Program Formulary updates September P, F, A

Contraceptive coverage changes for 2016 December P

Coverage of non-FDA-approved drugs December P

Important message for providers who prescribe drugs for Medicare patients December P

Our prescription drug program and safe prescribing procedures December P

Prescribing medications for your older adult patients December P

Prescription drug updates December P, F, A

Select Drug Program Formulary updates December P, F, A

Upcoming changes in coverage for intrauterine devices December P

ProductsArticle title Edition Audience

Upcoming Medicare Advantage HMO benefit changes October P, F, A

Member benefit changes and clarifications for Pennsylvania commercial members November P, F, A

AmeriHealth New Jersey introduces AmeriHealth Advantage December P, F, A

Clarification: New routine chiropractic and podiatry benefits for Medicare Advantage plans in 2016 December P

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Partners in Health Update

Quality ManagementArticle title Edition Audience

Ensure patients know how to access care after office hours January P

Highlighting HEDIS®: Cervical cancer screening January P

Highlighting HEDIS®: Pharmacotherapy management of COPD exacerbation February P

Highlighting HEDIS®: Appropriate testing for children with pharyngitis March P

Highlighting HEDIS®: Well-child visits in the first 15 months of life April P

AmeriHealth encourages medical and behavioral health providers to work together May P, F

Highlighting HEDIS®: Well-child visits in the third, fourth, fifth, and sixth years of life May P

Highlighting HEDIS®: Osteoporosis management in women who had a fracture July P

Highlighting HEDIS®: Weight assessment and counseling for nutrition and physical activity for children/adolescents August P

AmeriHealth members rate their physician experience October P

AmeriHealth offers services to help patients communicate October P

Highlighting HEDIS®: Breast cancer screening October P

Policy reminder regarding utilization review decisions November P, F

Standards for medical record documentation: When there is a consultation November P

The AmeriHealth Quality Management Program promotes quality of care and service November P, F, A

2015-2016 Clinical Practice Guideline Summary now available December P

2015-2016 Member Wellness Guidelines now available December P

Standards for medical record documentation: Medical record review December P, F, A