home | providers - table of contents · 2020. 6. 29. · circulatory system, such as the following:...

Amerigroup Community Care complies with all applicable federal and state civil rights laws, rules and regulations and does not discriminate against members/participants in the provision of services on the basis of race, color, national origin, religion, sex, age or disability. To report a discrimination complaint or to request language, communication or disability assistance for a member/participant, call 1-800-600-4441. Information about civil rights laws can be found on our website and is available from the U.S. Department of Health and Human Services.

z July 2020 TN-NB-0322-20

July 2020

Table of Contents

Medicaid:

Submit behavioral health authorizations via our online Interactive Care Reviewer tool

Page 2

Coding spotlight: Provider guide to coding for cardiovascular conditions

Page 2

Updates to AIM Specialty Health advanced imaging Clinical Appropriateness Guidelines

Page 6

CLIA requirement clarifications Page 7

Outpatient laboratory services — new payment policy Page 9

Medically necessary services obtained from non-contract provider referred by contract provider

1

Medicare Advantage:


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COVID-19 update: Guidance for telehealth/telephonic care for Medicare Advantage behavioral health services

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Prior authorization codes moving from AIM Specialty Health to Amerigroup Community Care

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Updates to AIM musculoskeletal program clinical appropriateness guidelines for all lines of business

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Medical drug benefit Clinical Criteria updates Page 18

Special section: Long-Term Services and Supports (LTSS):

Employment and Community First CHOICES community integration opportunity

Page 19

Workforce development Page 20

Employment and Community First CHOICES team updates Page 20

Long-term services and supports Provider Relations territory listing, provider contact information and reminders

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https://www.myamerigroup.com/Documents/TNTN_NeedHelpandCivilRights_ENG.pdf

https://www.hhs.gov/ocr/index.html

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Medicaid: * Availity, LLC is an independent company providing administrative support services on behalf of Amerigroup Community Care. AIM Specialty Health is an independent company providing some utilization review services on behalf of Amerigroup Community Care. Quest is an independent company providing lab services on behalf of Amerigroup Community Care. LabCorp is an independent company providing lab services on behalf of Amerigroup Community Care.


Summary of change: Effective June 15, 2020, Amerigroup Community Care is excited to announce an enhanced process for submitting behavioral health authorization requests via the Interactive Care Reviewer (ICR) tool. The enhanced ICR tool will provide the opportunity for quicker decisions and eliminate wait times associated with faxes and telephonic intake. The ICR tool will use sophisticated clinical analytics to approve an authorization instantly for higher levels of care such as inpatient, intensive outpatient and partial hospitalization. Benefits of the new ICR tool include:

Reduction of administrative burden.

Quicker access to care — 15 minutes for approval in some cases.

Increased patient focus.

Prioritization of more complex cases.

Reduced possibility of errors (such as illegible faxes).

Increased time spent with patients. Access the ICR tool via the Availity* Portal.

TNPEC-3281-20

Coding spotlight: Provider guide to coding for cardiovascular conditions

In this coding spotlight, we will focus on several cardiovascular conditions; The ICD (International Classification of Diseases) codes from Chapter 9 of the ICD-10-CM are listed in the table below.

Diseases of the circulatory system Category codes

Acute rheumatic fever I00-I02

Chronic rheumatic heart diseases I05-I09

If you have questions about any of the articles contained in this NewsBlast or need assistance, contact your local Provider Relations representative or call Provider Services at the toll-free phone numbers listed below:

Medicaid providers call 1-800-454-3730.

Medicare providers call 1-866-805-4589.

https://www.availity.com/

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Hypertensive diseases I10-I16

Ischemic heart diseases I20-I25

Pulmonary heart disease and diseases of pulmonary circulation I26-I28

Other forms of heart disease I30-I52

Cerebrovascular diseases I60-I69

Diseases of arteries, arterioles and capillaries I70-I79

Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified I80-I89

Other and unspecified disorders of the circulatory system I95-I99

Hypertension ICD-10-CM classifies hypertension by type as essential or primary (categories I10 to I13) and secondary (category I15). Categories I10 to I13 classify primary hypertension according to a hierarchy of the disease from its vascular origin (I10) to the involvement of the heart (I11), chronic kidney disease (I12), or heart and chronic kidney disease combined (I13).1

Elevated blood pressure versus hypertension A diagnosis of elevated blood pressure reading, without a diagnosis of hypertension, is assigned code R03.0. This code is never assigned on the basis of a blood pressure reading documented in the medical record; the physician must have specifically documented a diagnosis of elevated blood pressure. The postoperative hypertension is classified as a complication of surgery, and code I97.3, post procedural hypertension, is assigned. When the surgical patient has pre-existing hypertension, only codes from categories I10 to I13 are assigned.

Hypertensive heart disease ICD-10-CM presumes a causal relationship between hypertension and heart involvement and classifies hypertension and heart conditions to category I11 — hypertensive heart disease — because the two conditions are linked by the term with in the alphabetic index of the ICD-10-CM. These conditions should be coded as related even in the absence of provider documentation linking them. First, code I11.0, hypertensive heart disease with heart failure as instructed by the note at category I50, heart failure. If the provider specifically documents different causes for the hypertension and the heart condition, then the heart condition (I50.-, II51.4-I51.9) and hypertension are coded separately.1

Other heart conditions that have an assumed causal connection to hypertensive heart disease Code Description

I51.4 Myocarditis, unspecified

I51.5 Myocardial degeneration

I51.7 Cardiomegaly

I51.81 Takotsubo syndrome

I51.89 Other ill-defined heart diseases

I51.9 Heart disease, unspecified

Hypertension, secondary Two codes are required: one to identify the underlying etiology and one from category I15 to identify the hypertension. For example:

Hypertension due to systemic lupus erythematosus, M32.10 + I15.8.

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Hypertensive crisis A code from category I16, hypertensive crisis, is assigned for any documented hypertensive urgency (I16.0), hypertensive emergency (I16.1), or unspecified hypertensive crisis (I16.9). Report two codes, at a minimum, for hypertensive crisis. The crisis code is reported in addition to the underlying hypertension code (I10-I15).1

Pulmonary hypertension Pulmonary hypertension is classified to category I27, other pulmonary heart diseases. For secondary pulmonary hypertension (I27.1, I27.2-), any associated conditions or adverse effect of drugs or toxins should be coded.2

Ischemic heart disease Category I25, chronic ischemic heart disease, includes coronary atherosclerosis, old myocardial infarction, coronary artery dissection, chronic coronary insufficiency, myocardial ischemia and aneurysm of the heart. ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, atherosclerotic heart disease with angina pectoris and I25.7, atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris. When using one of these combination codes, it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates that angina is due to a condition other than atherosclerosis.2

Heart failure Systolic heart failure is coded as I50.2 and diastolic heart failure is coded as I50.3-; combined systolic and diastolic heart failure is assigned code I50.4. Fifth characters further specify whether the heart failure is unspecified, acute, chronic or acute on chronic. Other classifications of heart failure include:

Right heart failure, unspecified (I50.810)

Acute right heart failure (I50.811)

Chronic right heart failure (I50.812)

Acute on chronic right heart failure (I50.813)

Right heart failure due to left heart failure (I50.814)

Biventricular heart failure (I50.82)

High output heart failure (I50.83)

End-stage heart failure (I50.84)

Other heart failure (I50.89)

Unspecified (I50.9) For a diagnosis of left ventricular, biventricular and end-stage heart failure, two codes are required to completely describe the condition: one to report the left, biventricular or end-stage heart failure, and one to identify the type of heart failure.

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Cardiomyopathy Cardiomyopathy is coded as I42- with the third character describing:

I42.0 Dilated cardiomyopathy, which includes congestive cardiomyopathy

I42.1 Obstructive hypertrophic cardiomyopathy, including idiopathic hypertrophic subaortic stenosis

I42.2 Other hypertrophic cardiomyopathy, including nonobstructive hypertrophic cardiomyopathy

I42.3 Endomyocardial (eosinophilic) disease, including endomyocardial (tropical) fibrosis and Loffler’s endocarditis

I42.4 Endocardial fibroelastosis, including congenital cardiomyopathy and elastomyofibrosis

I42.5 Other restrictive cardiomyopathy, including constrictive cardiomyopathy not otherwise specified

I42.6 Alcoholic cardiomyopathy due to alcohol consumption: a code for alcoholism (F10.-) is also assigned if present

I42.7 Cardiomyopathy due to drug and external agent: code first the poisoning due to drug or toxin; if applicable (T36-T65 with fifth or sixth character 1-4 or 6); if the condition is caused by an adverse effect, use an additional code, if applicable, to identify the drug (T35-T50 with fifth or sixth character)

I42.8 Other cardiomyopathies

I42.9 Unspecified Two codes may be required for cardiomyopathy due to other underlying conditions; for example, cardiomyopathy due to amyloidosis is coded E85.4, organ-limited amyloidosis, and I43, cardiomyopathy in diseases classified elsewhere. The underlying disease, amyloidosis, is sequenced first.2

Status Z codes ICD-10-CM provides several Z codes to indicate that the patient has a health status related to the circulatory system, such as the following:

Z94.1 Heart transplant status

Z95.0 Presence of cardiac pacemaker

Z95.1 Presence of aortocoronary bypass graft

Z95.810 Presence of automatic (implantable) cardiac defibrillator

Z95.811 Presence of heart assist device

Z95.828 Presence of other vascular implants and grafts. These codes are assigned only as additional codes and are reportable only when the status affects the patient’s care for a given episode.

Resources 1 ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2020. 2 ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier

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Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Specialty Health®* advanced imaging of the chest, vascular imaging and AIM oncologic imaging Clinical Appropriateness Guidelines. Vascular imaging updates by section

Aneurysm of the abdominal aorta or iliac arteries: o Added new indication for asymptomatic enlargement by imaging o Clarified surveillance intervals for stable aneurysms as follows:

Treated with endografts, annually Treated with open surgical repair, every five years

Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified: o Added surveillance indication and interval for surgical bypass grafts

Advanced imaging of the chest updates by section

Tumor or neoplasm: o Allowed follow-up of nodules less than six mm in size seen on incomplete

thoracic CT scan, in alignment with follow-up recommendations for nodules of the same size seen on complete thoracic CT scan

o Added new criteria for which follow-up is indicated for mediastinal and hilar lymphadenopathy

o Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry

Parenchymal lung disease —not otherwise specified: o Removed as it is covered elsewhere in the document (parenchymal disease in

occupational lung diseases and pleural disease in other thoracic mass lesions)

Interstitial lung disease, nonoccupational including idiopathic pulmonary fibrosis: o Defined criteria warranting advanced imaging for both diagnosis and

management

Occupational lung disease (adult only): o Moved parenchymal component of asbestosis into this indication o Added berylliosis

Chest wall and diaphragmatic conditions: o Removed screening indication for implant rupture due to lack of evidence

indicating that outcomes are improved o Limited evaluation of clinically suspected rupture to patients with silicone

implants Oncologic imaging updates by section

MRI breast: o New indication for breast implant associated anaplastic large cell lymphoma o New indication for pathologic nipple discharge o Further define the population of patients most likely to benefit from

preoperative MRI

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Breast cancer screening: o Added new high-risk genetic mutations appropriate for annual breast MRI

screening

Lung cancer screening: o Added asbestos-related lung disease as a risk factor

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

Access AIM’s ProviderPortalSM directly online. Online access is available 24/7 to process orders in real time, and is the fastest and most convenient way to request authorization.

Access AIM via the Availity Portal.*

Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m.

If you have questions related to guidelines, please contact AIM via email at [email protected]. Additionally, you can access and download a copy of the current and upcoming guidelines here.

TN-NB-0306-20

CLIA requirement clarifications

Background: Amerigroup Community Care implemented Clinical Laboratory Improvement Amendments (CLIA) requirements for claims with dates of service on or after September 15, 2019, for CLIA certification validation. Our system reads directly from the CMS Provider of Service (POS) CLIA file to validate CLIA information. CMS updates this file every three months. To ensure your claims process correctly and the POS files are current, we strongly advise that providers proactively submit an updated CLIA certificate three months prior to the CLIA certification expiration date. Laboratory procedures are only covered and, therefore, payable if rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code or does not have complete servicing provider demographic information will be considered incomplete and rejected or denied. Please note: All out of network providers require an authorization. Claim submission requirements Professional service and independent laboratory providers are required to include a valid CLIA number on all claims submitted for laboratory services, including CLIA-waived tests. The CLIA certificate identification number must be submitted in one of the following manners:

https://providerportal.com/


http://www.aimspecialtyhealth.com/ClinicalGuidelines.html

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Claim format and elements

CLIA number location options

Referring provider name and NPI number location options

Servicing laboratory physical location

CMS-1500 (formerly HCFA-1500), paper claim

Must be represented in field 23

Submit the referring provider name and NPI number in fields 17 and 17b, respectively.

Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the address is not equal to the billing provider address. The servicing or billing provider address must match the address associated with the CLIA ID entered in field 23.

HIPAA 5010 837 professional, electronic claim

Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01

Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.

Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address. The servicing or billing provider address must match the address associated with the CLIA ID submitted in the 2300 loop, REF02.

This is an example of valid CLIA number format: 19DXXXXXXX.

The first three characters are the two-digit state code followed by the letter D.

The remaining seven digits are the unique CLIA system number assigned to the provider.

Do not add the letters CLIA to the 10-character CLIA number. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier for CLIA waived laboratory service when reported on a CMS-1500 claim form in order for the procedure to be evaluated to determine eligibility for benefit coverage. Claim rejection/denial reason codes:

GLI — Valid CLIA number must be submitted: o The CLIA number is missing or invalid. o CLIA is not valid for claim dates of service. o The CMS address for CLIA does not match the address in box 32 or 33 of the

CMS-1500 form.

GLJ — CLIA number invalid for services: o This denial code is applied to the claim line if the provider is billing for services

that are beyond the scope of this CLIA certification level. o This edit should only apply to providers who have CLIA Certificate of Waiver or a

Certificate for Provider-Performed Microscopy Procedures.

Z71 — QW modifier (all of the following must apply): o The provider has a Certificate of Waiver CLIA level. o The service billed requires a QW modifier per current CMS list of waived codes.

The provider did not bill the QW modifier as required per CMS.

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Outpatient laboratory services — new payment policy Summary of change: Effective July 1, 2020, most outpatient laboratory tests must be sent to Quest,* LabCorp* or other participating outpatient laboratories as listed in the provider directory. Laboratory tests may be performed in a physician’s office certified by the Clinical Laboratory Improvement Amendments (CLIA). Authorizations will be required for non-participating providers for laboratory testing. Why is this change necessary? Amerigroup Community Care is revising our payment policy for outpatient laboratory services to ensure they are performed in the most appropriate setting. In many cases, a hospital should not be the lab of reference. What does this mean to me? All outpatient laboratory tests must be sent to a participating outpatient laboratory or be performed at a CLIA-certified physician’s office with the following exceptions:

Lab services rendered in an emergency room setting

Lab services rendered in conjunction with hospital observation services: RV0760-V0769

Lab services required for pre-admission testing for hospital inpatient admission

Lab services rendered in conjunction with ambulatory surgery services: RV0360-RV0369, RV0481, RV0490-RV0499, RV0720-RV0729, RV0750-RV0759 and RV0790-RV0799

Lab services that are billed with the following diagnosis codes: o Obstetric: O00-O08, O09, O10-O16, O20-O29, O30-O48, O60-O77, O80-O82,

O85-O92, O94-O9A, Z30-Z39 o Chemotherapy: Z51.11, Z92.21, Z01.818 o Neoplasms: C00-C14, C15-C26, C30-C39, C40-C41, C43-C44, C45-C49, C50, C51-

C58, C60-C63, C64-C68, C69-C72, C73-C75, C7A, C7B, C76-C80, C81-C96, D00-D09, D10-D36, D3A, D37-D48, D49

o Sickle cell: D57.00, D57.01, D57.02, D57.1, D57.20, D57.211, D57.212, D57.219, D57.3, D57.40, D57.411, D57.412, D57.419, D57.80, D57.811, D57.812, D57.819

STAT labs identified by CPT code in Table below:

CPT® Description CPT Description CPT Description

80048 Basic metabolic panel

80164 Dipropylacetic acid

80194 Quinidine

80051 Electrolyte panel

80178 Lithium 80329, 80330, 80331

Salicylate

80076 Hepatic function panel

80184 Phenobarbital 80198 Theophylline

80156 Carbamazepine; total

80185 Phenytoin; total 80200 Tobramycin

80162 Digoxin 80192 Procainamide; with metabolites

81000 Urinalysis by dipstick or tablet reagent for bilirubin, glucose, etc.; nonautomated, with microscopy

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81001 Urinalysis by dipstick or tablet reagent; auto with micro

82670 Estradiol 85044 Blood count; reticulocyte manual

81003 Urinalysis by dipstick or tablet reagent; without micro auto

82947 Glucose; quantitative blood

85045 Blood count; reticulocyte automated

81025 Urine pregnancy test visual color compare methods

83045 Hemoglobin; methemoglobin qualitative

85384 Fibrinogen; activity

80329, 80321, 80322

Acetaminophen 83050 Hemoglobin; methemoglobin quantitative

85032 Platelet; manual count

80320, 80321, 80322

Alcohol; any specimen except breath

83690 Lipase 85049 Platelet; automated count

82140 Ammonia 83735 Magnesium 85610 Prothrombin time

82150 Amylase 84132 Potassium; serum

85384 Fibrinogen; activity

82247 Bilirubin; total 84520 Urea nitrogen; quantitative

85590 Platelet; manual count

82310 Calcium; total 84702 Gonadotropin chorionic; quantitative

85651 Sedimentation rate erythrocyte; nonautomated

82375 Carbon monoxide; quantitative

84703 Gonadotropin chorionic; qualitative

85730 Thromboplastin time partial; plasma/whole blood

82550 Creatine kinase; total

85025 Blood count; complete auto and auto differential white blood cell count

86308 Heterophile antibodies; screening

82565 Creatinine; blood

85031 Blood count; Hemogram manual complete CBC

87205 Smear, primary source with interpretation; Gram/Giemsa Stain

Any laboratory services not on the STAT lab list above, performed by a Tennessee hospital or nonparticipating laboratory, will be denied with the following: Service billed not on Amerigroup approved STAT lab list.

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Medically necessary services obtained from non-contract provider referred by contract provider

Effective July 1, 2020, Amerigroup Community Care participating providers should not refer members to out-of-network (OON) providers without the appropriate authorization. Services provided by an OON provider are only covered if an emergency condition exists or an approved authorization has been granted. If Amerigroup receives a claim from an OON provider who does not meet the required standards or have an authorization, the claim will be denied.

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Medicare Advantage: Coverage provided by Amerigroup Inc.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Amerigroup Community Care. LiveHealth Online is an independent company offering telehealth services on behalf of Amerigroup Community Care. Availity, LLC is an independent company providing administrative support services on behalf of Amerigroup Community Care.


View the full article in the Medicaid section.

TNPEC-3281-20/AGPCARE-0486-20


View the full article in the Medicaid section.

TN-NB-0306-20

COVID-19 update: Guidance for telehealth/telephonic care for Medicare Advantage behavioral health services

Amerigroup Community Care is closely monitoring COVID-19 developments and what it means for our customers and our health care provider partners. Our clinical team is actively monitoring external queries and reports from the Centers for Disease Control and Prevention (CDC) to help us determine what action is necessary on our part. We have made changes to how behavioral health providers can use and be compensated for telehealth (audio + video) and telephonic-only care with their patients. To help address care providers’ questions regarding behavioral health services, Amerigroup has developed the following frequently asked questions.

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Please continue to visit this website regularly, as we will be updating the information as it becomes available. Thank you for the work you do for our members, especially during these difficult times. Telehealth (audio + video) Effective March 17, 2020, through September 30, 2020, Amerigroup will waive member cost shares for telehealth visits including visits from in-network providers for mental health or substance use disorders for our Medicare Advantage plans, where permissible. Cost sharing will be waived for members using our authorized telemedicine service LiveHealth Online* as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program. For out-of-network providers, Amerigroup is waiving cost shares from March, 17, 2020, through June 14, 2020. How is Amerigroup approaching the provision of mental health outpatient, substance abuse outpatient, Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), applied behavioral analysis (ABA), psychological and neuropsychological testing services via telehealth (audio + video) visits? Amerigroup is making adjustments in our policy in the provision of these services to address the need for expanded telehealth access. We expect all mental health outpatient, substance abuse outpatient, IOP, PHP, ABA, and psychological testing services will still be provided within benefit limits, authorization limits, medical necessity criteria, and within state and federal regulatory requirements and licensure requirements, including HIPAA compliance and the regulations regarding how substance use information is handled. These changes for telehealth visits are effective March 17, 2020, and will stay in place through September 30, 2020. We will continue to actively monitor the rapidly evolving situation. What codes would be appropriate to consider for IOP and PHP services using telehealth (audio + video)? Amerigroup would recognize IOP and PHP services that are rendered via telehealth with a revenue code (905, 906, 912, 913), plus CPT codes for specific behavioral health services. Are there any recommendations around the delivery of PHP level of care using telehealth (audio+ video)?

PHP programs should continue to deliver the same level of service and clinical value using telehealth.

Telehealth refers to use of audio + video, not solely telephonic (audio only). Telephonic-only interactions are not appropriate for PHP level of care.

Expectation of telehealth PHP services being delivered includes but is not limited to: o Maintain daily psychiatric management and active treatment comparable to that

provided in an inpatient setting. o Ensure full day telehealth PHP program is delivered in the same way as an

in-person, face-to-face PHP program including therapeutically intensive acute treatment within a therapeutic milieu including individual and group therapy.

o Routine discharge processes are followed including scheduling after-care appointments no more than seven days from a member’s discharge from PHP and ensuring that members discharged on medication receive at least one psychiatric medication monitoring appointment no more than 14 days after discharge.

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o Group therapy takes place at the same levels as delivered in PHP face-to-face program.

o Group therapy size should be the same as when PHP program is delivered in person, face-to-face.

o Clinical assessment of the member takes place once daily. o Educational and activity therapies are included as indicated on the treatment

plan. o Treatment planning and progress notes documentation of services delivered. o Documentation that services were provided via telehealth (audio +video). o Protocols in place to address risk behavior and decompensation. o Process in place to respond to crisis for members. o Consent and privacy controls are put in place when patients are participating in

group telehealth (audio+ video) sessions. o Protocols in place to address risk behavior and decompensation in the patient’s

home. Utilization management process for PHP:

o Providers are expected to follow any required prior authorization and concurrent review process for the PHP authorization process.

Are there any recommendations around the delivery of intensive IOP level of care using telehealth (audio+ video)?

IOP programs should continue to deliver the same level of service and clinical value using telehealth.

Telehealth refers to use of audio +video, not solely telephonic. Telephonic-only interactions are not appropriate for IOP level of care.

Expectation of telehealth IOP services being delivered includes but is not limited to: o Maintain timely admittance to the program within one business day of

evaluation, along with timely completion of initial treatment plan and discharge plan.

o Ensure telehealth psychiatric management is comparable to face-to-face IOP care.

o Routine discharge processes are followed including scheduling after-care appointments no more than seven days from a member’s discharge from IOP and ensuring that members discharged on medication receive at least one psychiatric medication monitoring appointment no more than 14 days after discharge.

o Ensure access to multidisciplinary treatment team (for example, clinical master’s degree staff, RN, psychiatrist).

o Continue to provide daily management and active treatment. o Maintain a written schedule of program activities. o Treatment planning and progress notes documentation of services delivered. o Documentation that services were provided via telehealth (audio +video). o Protocols in place to address risk behavior and decompensation. o Process in place to respond to crisis for members. o Consent and privacy controls are put in place when patients are participating in

group telehealth (audio + video) sessions.

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Utilization management process for IOP: o Providers are expected to follow any required prior authorization and concurrent

review process for the IOP authorization process. What codes would be appropriate to consider for mental health and substance abuse outpatient services using telehealth (audio + video)? Amerigroup would recognize psychiatric diagnostic evaluation (90791-90792), psychotherapy (90832-90838, 90839-90840, 90845-90847), and medication management (90863) and E&M codes (99211-99215) visits within the member’s benefits, with place of service (POS) 02 and modifier 95 or GT. Please report these mental health and substance abuse outpatient telehealth services with POS 02 only. What codes would be appropriate to consider for the delivery of ABA therapy using telehealth (audio + video)? Amerigroup would recognize ABA therapy for functional behavior assessment (FBA) (97151) adaptive behavioral treatment by protocol or protocol modification (97153, 97155) and telehealth caregiver training (97156, 97157) visits within the member’s benefits, with POS 02 and modifier 95 or GT. Please report these ABA therapy telehealth services with POS 02 only. Are ABA providers allowed to use the hours approved in a current authorization for telehealth (audio + video) ABA services? If an ABA provider is not requesting changes to existing authorized codes or units, they can continue to use the authorization they have on file. No further action is required by the provider. If an ABA provider is requesting changes to the authorization we have in place, such as changes to units or codes, they must submit a request for the change by submitting a new treatment request form outlining the changes they are requesting. Please include current authorization reference number and date of change being requested. If an ABA provider is requesting new authorization of code or units, they should follow the process already in place by submitting the request via fax or via our electronic portal. Telephonic-only care Amerigroup does not cover these services today (with limited state exceptions) effective March 19, 2020, through September 30, 2020, Amerigroup will cover telephonic-only visits with in-network providers where permissible. Out-of-network coverage will be provided within benefit guidelines and within any prior authorization requirements that apply. This includes visits for behavioral health, for our Medicare Advantage plans, where permissible. Cost shares will be waived for in-network providers only. Self-insured plan sponsors may opt out of this program. Exceptions include intensive outpatient services, PHP, psychological testing and ABA services. These services require face-to-face interaction and, therefore, are not appropriate for telephonic-only consultations. Self-insured plan sponsors may opt out of this program.

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How is Amerigroup approaching the provision of mental health outpatient and substance abuse outpatient services via telephonic-only visits? Amerigroup is making adjustments in our policy in the provision of these telephonic-only services to address the need for expanded access outside of telehealth (audio + video) to include telephonic-only visits with in-network providers and out-of-network providers where required. We expect all mental health outpatient and substance abuse outpatient care will still be provided within benefits limits, authorization limits, medical necessity criteria, and within state and federal regulatory requirements and licensure requirements including HIPAA compliance and the regulations regarding how substance use information is handled. These changes for telephonic-only visits are effective March 19, 2020, through September 30, 2020. We will continue to actively monitor the rapidly evolving situation. What codes would be appropriate to consider for mental health outpatient and substance abuse outpatient services via telephonic audio-only visits? Effective March 19, 2020, through September 30, 2020, Amerigroup would recognize audio-only time based codes, (99441, 98966, 99442, 98967, 99334, 98968). These codes do not need a place of service (POS) 02 or modifier 95 or GT. In addition, Amerigroup would recognize telephonic-only services for diagnostic evaluation (90791-90792), psychotherapy (90832-90838, 90839-90840, 90845-90847), and medication management (90863) with POS 02 and modifier 95 or GT. For Medicare Advantage business, please report these telephonic-only services with POS 02 only. Can behavioral health providers conduct IOP, PHP, psychological testing and the ABA services via telephonic-only care? No, these services require face-to-face interaction and, therefore, are not appropriate for telephonic-only consultations. Amerigroup is allowing these services to be billed via telehealth (audio + video). What if I have additional questions pertaining to behavioral health telehealth (audio + video) or telephonic-only care visits? Please contact our Behavioral Health department.

AGPCARE-0515-20

Prior authorization codes moving from AIM Specialty Health to Amerigroup Community Care

AIM Specialty Health®* (AIM) currently performs utilization management review for bilevel positive airway pressure (BiPAP) equipment and all associated supplies. Beginning July 1, 2020, the following codes will require prior authorization with Amerigroup rather than with AIM.

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Line of business: Individual Medicare Advantage, Group Retiree Solutions, and Medicare-Medicaid Plans

E0470 Respiratory assist device, bilevel pressure capability, without back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

AIM will continue to manage the supply codes for automatic positive airway pressure (APAP) and continuous positive airway pressure (CPAP) requests. Amerigroup will continue to follow the COVID-19 Public Health Emergency orders from CMS until the waivers no longer apply. If the Public Health Emergency Orders are no longer in place beginning July 1, 2020, the following codes will require prior authorization with Amerigroup rather than with AIM when used in combination with the BiPAP codes above. Precertification requests Submit precertification requests via:

Fax — 1-866-959-1537

Phone — Please dial the customer service number on the back of the member’s card, identify yourself as a provider and follow the prompts to reach the correct precertification team. There are multiple prompts. Select the prompt that fits the description for the authorization you plan to request

Web — Use the Availity* Web Tool

A4604 Tubing with heating element

A7046 Water chamber for humidifier, replacement, each

A7027 Combination Oral/Nasal Mask used with positive airway pressure device, each

A7030 Full Face Mask used with positive airway pressure device, each

A7031 Face Mask Cushion, Replacement for Full Face Mask

A7034 Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head strap

A7035 Headgear

A7036 Chinstrap

A7037 Tubing

A7039 Filter, non-disposable

A7044 Oral Interface for Positive Airway Pressure Therapy

A7045 Replacement Exhalation Port for PAP Therapy

A7028 Oral Cushion, Replacement for Combination Oral/Nasal Mask, each

A7029 Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair

A7032 Replacement Cushion for Nasal Application Device

A7033 Replacement Pillows for Nasal Application Device, pair

A7038 Filter, disposable

AGPCARE-0513-20

https://apps.availity.com/availity/web/public.elegant.login

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Updates to AIM musculoskeletal program clinical appropriateness guidelines for all lines of business

Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Specialty Health® (AIM)* musculoskeletal program joint surgery, spine surgery and interventional pain clinical appropriateness guidelines.

Joint surgery updates by section Shoulder arthroplasty:

Added steroid injection for all joints exclusion based on panel recommendation

Added exclusions for use of xenografts or biologic scaffold for augmentation or bridging reconstruction, use of platelet rich plasma or other biologics and concomitant subacromial decompression

Removed indication for subacromial impingement with rotator cuff tear Hip arthroplasty:

Added exclusion for steroid injection for joint being replaced within the past six weeks

Added labral tear indication

Knee arthroscopy and open procedures:

Added chondroplasty indication

Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella

Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section

Musculoskeletal program interventional pain management guideline updates by section General requirements — conservative management:

Addition of physical therapy or home therapy requirement and one complementary modality based on preponderance of benefit over harm to conservative care

Align with approach to conservative management defined in spine and joint surgery guidelines

Epidural injection procedures and diagnostic selective nerve root blocks:

Addition of statement about adherence to ESI procedural best practices established by FDA Safe Use Initiative

o Recommendations are intended for provider education and will not be used for adjudication.

Clarification of intent around requirement for advanced imaging for repeat injections Paravertebral facet injection/nerve block/neurolysis:

Remove indication for four unilateral medial branch blocks per session based on panel consensus

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Paravertebral facet injection/nerve block/neurolysis continued:

Procedural clarification restricting use of corticosteroids for diagnostic MBB based on panel consensus

Limit use of intra-articular steroid injection to mechanical disruption of a facet synovial cyst

Remove indication for intra-articular steroid injections based on new evidence for lack of efficacy

Increase duration of initial RFN efficacy needed to avoid a MBB to six months based on panel consensus

Clarification that MBB or RFN is not medically necessary after spinal fusion Spinal cord and nerve root stimulators:

Clarify inclusion of different stimulation methods for spinal cord stimulation

Add new indication for dorsal root ganglion stimulation

Clarify exclusions for spinal cord and dorsal root ganglion stimulation

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

Access the AIM Provider PortalSM directly here. o Online access is available 24/7 to process orders in real-time, and is the

fastest and most convenient way to request authorization.

Access AIM via the Availity* Portal here.

Call the AIM Contact Center toll-free number at 1-800-714-0040. o Associates are available 7:00 a.m. to 7:00 p.m. ET.

If you have questions related to guidelines, please contact AIM via email at [email protected]. Additionally, you may access and download a copy of the current and upcoming guidelines here.

AGPCRNL-0112-20

Medical drug benefit Clinical Criteria updates On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Amerigroup Community Care. These policies were developed, revised or reviewed to support clinical coding edits. The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

AGPCRNL-0119-20

https://providerportal.com/


http://www.aimspecialtyhealth.com/ClinicalGuidelines

https://www11.anthem.com/pharmacyinformation/clinicalcriteria/home.html

mailto:[email protected]

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Employment and Community First CHOICES

community integration opportunity

Are you looking for a new option to provide community integration services for individuals

interested in self-advocacy? Bring people supported through Amerigroup Community Care to

the quarterly Advisory Board meeting, where they can be involved in an integrated setting of

people committed to advocating for those in the Employment and Community First CHOICES

(ECF CHOICES) program. We welcome all ideas and communication skill levels.

ECF CHOICES is designed to help people with disabilities find and keep a job, learn new skills,

meet new people, and gain as much independence as possible. To keep our program at its best,

we need feedback from the people we support. By participating in Advisory Board meetings,

they can make recommendations on services and supports to Amerigroup and the Division of

TennCare; help to make policies and procedures; give input on the planning and delivery of

services; receive training on topics like housing, employment and community resources; and

connect with providers, caregivers, other members and their families. Individuals enrolled in

ECF CHOICES who come to a meeting will get $50 or the cost of travel, whichever is greater.

Contact your regional member advocate for details:

Region Member advocate Contact information

West Ruth Romines 1-629-215-0142

[email protected]

Middle Stacey Irish 1-615-708-3082

[email protected]

East Judy Pate 1-615-483-0853

[email protected]

Special section: Long-Term Services and Supports (LTSS)

Employment and Community First CHOICES community integration opportunity

Page 19

Workforce development Page 20

Employment and Community First CHOICES team updates

Page 20

Long-term services and supports Provider Relations territory listing, provider contact information and reminders

Page 21

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Workforce development Providers are facing significant and widespread challenges here in Tennessee when it comes to recruiting, hiring and retaining sufficient direct support professionals (DSPs) to meet the needs of individuals supported by Amerigroup Community Care. Did you know there was a 46% DSP turnover rate in 2018 and a 15% vacancy rate? This means that nearly half of the DSP workforce left their positions that year, and about one out of every seven DSP positions is vacant in Tennessee. Amerigroup is working with the University of Minnesota’s Institute of Community Integration, the Division of TennCare and other MCOs to provide resources and personal technical assistance. Together, we are going to make a difference for the members that we serve.

“Great things in business are never done by one person; they’re done by a team of people.” – Steve Jobs

Employment and Community First CHOICES

team updates

Employment and Community First CHOICES (ECF CHOICES) is in its fourth year of operation and

continues to grow and work to enhance the lives of individuals with intellectual and

developmental disabilities (I/DD). As we grow, we strive to keep our providers up to date on

our organizational changes. We are excited to share with our provider network that over the

last few months, we have made some additions to our ECF CHOICES and Provider Relations

team.

Carrie Guiden joined Amerigroup Community Care on April 20, 2020, as the Director, Special

Programs, leading the ECF CHOICES program. Carrie brings many years of experience to our

team, with a background in advocacy for individuals with I/DD. Carrie has worked with the

Division of TennCare since 2009 and through the implementation of TennCare CHOICES and ECF

CHOICES. We are excited to have Carrie’s passion, experience and knowledge added to our

team.

Grace McDonald joined Amerigroup on March 9, 2020, as the Behavioral Health Liaison for ECF CHOICES. Grace brings a wealth of knowledge from her time as a behavioral analyst. Gracewill be working with Dr. Settle and our Support Coordination team to support individuals receiving services with ECF CHOICES. Her experience and passion will be very valuable in her work with individuals in group 7 and 8, and we look forward to the support she will also provide to our ECF CHOICES provider network and our workforce development efforts. Maggie Evans has stepped into the Manager II, Special Programs position, leading the CLS and Intake/Enrollment teams for ECF CHOICES on March 2, 2020. Maggie has been a part of the ECF CHOICES team at Amerigroup since 2017, a key part of the CLS team, and has a leadership background with intake and case management functions. Maggie has 15 years of experience supporting individuals with I/DD.

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Joy Dalton moved into our Workforce Development Director position within the Provider Relations team on March 16, 2020. Joy is leading all efforts to collaborate with providers to enhance their workforce to best meet the needs of individuals receiving services in ECF CHOICES. The Tennessee Workforce Development initiative is a highly innovative movement established through working with the Division of TennCare, other MCOs in Tennessee, stakeholders and the community to address a national workforce crisis. Joy brings to this opportunity former experience as a DSP, a dual Masters in Business and Human Resources, a Provider Relations leadership background, and a notable passion to make a difference in the lives of those we serve and those who support them. We encourage and appreciate provider feedback; we ask that you reach out to anyone on our

team with your comments, suggestions or questions.

Name Position Phone Email

Carrie Guiden Director, ECF CHOICES 1-615-674-1210 [email protected]

Grace McDonald Statewide Manager of

Complex Coordination

1-615-762-0586 [email protected]

Gregg Hutchins Manager II 1-629-215-5016 [email protected]

Diana Bawcum Statewide Support

Coordination Lead


Raven Oliver West Support

Coordination Manager


Allison Cumming Middle Support

Coordination Manager


Alanna Rowcliffe Enrollment Operations

Manager

1-615-316-2400,

ext.1-106-126-0024

[email protected]

Skylyn Owens Quality Monitoring and

Reportable Events


Stephanie Potter Employment Specialist 1-901-481-2017 [email protected]

Tina Jones Employment Specialist 1-865-214-0765 [email protected]

Long-term services and supports Provider Relations territory listing,

provider contact information and reminders

In an effort to streamline correspondence to the appropriate Provider Relations representative

and to the correct internal department at Amerigroup Community Care, we are sharing the

most up-to-date contact information.

For any provider issue related to authorization requests (for example, authorization extensions,

authorization corrections, requests for a Person-Centered Support Plan, etc.), reach out to our

Authorization team at [email protected].

For any provider issue related to our electronic visit verification (EVV) system, HealthStar, (for

example, tablet requests, claims showing as rejected, etc.), reach out to our EVV team at

[email protected].

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To reach your Provider Relations representative, find our most up-to-date territory listing below. Please note, some counties are split between representatives. Please reach out to the regional managers if you are not able to identify who is your representative.

Name Title Region/counties served Contact information

Middle Grand region Sharita McCoy

Network Relations Manager

Middle Grand Region 1-615-218-9985 [email protected]

Roosevelt Fayne

Network Relations Consultant Sr.

Cheatham, Davidson (split for Employment and Community First CHOICES [ECF CHOICES] only), Dickson, Houston, Montgomery, Robertson, Stewart


Chiana Adair


Bedford, Coffee, Davidson (split for ECF CHOICES only), Giles, Hickman, Houston, Humphreys, Lawrence, Lewis, Lincoln, Marshall, Maury, Moore, Perry, Rutherford, Wayne and Williamson


Beth Ann Cartwright Network Relations Consultant Sr.

Cannon, Clay, Cumberland, Davidson (split for ECF CHOICES only), Dekalb Fentress, Jackson, Macon, Overton, Pickett, Putnam, Smith, Sumner, Trousdale, Warren, White, Wilson and Van Buren


East Grand region Katie Adcock


East Grand Region 1-865-440-9422 [email protected]

Lee-Ann Hartlett


Bledsoe, Campbell, Franklin, Grundy, Knox (A-J), Loudon, Hamilton (K-Z) Marion, Meigs, Rhea, Scott and Sevier, Addus-East servicing


Dana Scott


Carter, Claiborne, Cocke, Grainger, Greene, Hamblen, Hancock, Hawkins, Jefferson, Johnson, Sullivan, Unicoi and Washington, RHA Health Services


Monica Casey


Anderson, Blount, Bradley, Knox (K-Z) Hamilton (A-J), McMinn, Monroe, Morgan, Polk, Roane, Sequatchie and Union, Aging in Place-East servicing


West Grand region

Maria Robinson


West Grand Region 1-901-569-7350 [email protected]

Sheldon House


Dyer, Fayette, Haywood, Lauderdale, Shelby (N-Z) and Tipton


Karen Hughes


Benton, Carroll, Chester, Decatur, Gibson, Hardin, Henderson, Henry, Lake, Madison, McNairy, Obion and Weakley


Christopher Kea


Crockett, Hardeman and Shelby (A-M) 1-901-422-0626 [email protected]