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Provider Newsletter

September 2020NJ-NL-0436-20

September 2020

Table of ContentsCOVID-19 information from Amerigroup Community Care Page 2

CDC interim guidance for immunization services during the COVID-19 pandemic

Page 2

Medicaid:Patient360 Page 3

Medtox testing for blood lead levels Page 3

Medical drug Clinical Criteria updates Page 4

Prior authorization requirements for 0200T and 0201T Page 4

Medical Policies and Clinical Utilization Management Guidelines update

Page 5

Medicare Advantage:Medical drug Clinical Criteria updates Page 6

Update: Notice of changes to the AIM musculoskeletal program Page 7

Medical Policies and Clinical Utilization Management Guidelines update

Page 8

Updated September 11, 2020

Page 2 of 8

COVID-19 information from Amerigroup Community Care

Amerigroup is closely monitoring COVID-19 developments and how the novel coronavirus will impact our members and state partners. Our clinical team is actively monitoring external queries and reports from the Centers for Disease Control and Prevention (CDC) and the New Jersey Department of Health to help us determine what action is necessary on our part. Amerigroup will continue to follow New Jersey Department of Health guidance policies.

For additional information, reference the COVID-19 News and Resources section on the homepage of our website.NJPEC-2059-20

CDC interim guidance for immunization services during the COVID-19 pandemic

For Medicaid profiders:Importance of immunization services during the COVID-19 pandemicEfforts to reduce transmission of COVID-19, such as stay-at-home and shelter-in-place orders, have led to decreased use of routine preventive medical services, including immunization services. Ensuring that routine vaccination is maintained or reinitiated during the COVID-19 pandemic is essential for protecting individuals and communities from vaccine-preventable diseases and outbreaks. Routine vaccination prevents illnesses that lead to unnecessary medical visits, hospitalizations and further strain the health care system. For the upcoming influenza season, influenza vaccination will be paramount to reduce the impact of respiratory illnesses in the population and resulting burdens on the health care system during the COVID-19 pandemic. Communicating the importance of vaccination to patients and parents/caregivers as well as the safety protocols and procedures outlined in this guidance can help provide reassurance to those who may otherwise be hesitant to present for vaccination visits.

Vaccine recommendations during the COVID-19 pandemicRoutine vaccination is an essential preventive care service for children, adolescents and adults (including pregnant women) that should not be delayed because of the COVID-19 pandemic. In light of COVID-19-related reductions in people accessing vaccination services, it is important to assess the vaccination status of all patients at each visit to avoid missed opportunities for vaccination and ensure timely vaccine catch-up. All vaccines due or overdue should be administered according to the recommended CDC immunization schedules during that visit, unless a specific contraindication exists, to provide protection as soon as possible as well as minimize the number of healthcare visits needed to complete vaccination.

Additional considerations for influenza vaccination Annual influenza vaccination is recommended for all persons age six months and older to decrease morbidity and mortality caused by influenza. Health care providers should consult current influenza vaccine recommendations for guidance around the timing of administration and use of specific vaccines.

During the COVID-19 pandemic, reducing the overall burden of respiratory illnesses is important to protect vulnerable populations at risk for severe illness, the health care system, and other critical infrastructure. Thus, health care providers should use every opportunity during the influenza vaccination season to administer influenza vaccines to all eligible persons.

Strategies for catch-up vaccinationWith reduced vaccine administration during the COVID-19 pandemic, unvaccinated or undervaccinated patients are susceptible to preventable illness and communities are at risk for outbreaks. Thus, implementation of strategies to promote adherence to the vaccination schedule and ensure catch-up vaccination is important, especially for children. Reminder and recall systems should be implemented to identify patients who are due for or who have missed vaccine doses. IIS and electronic health records may be able to support this work. In addition, the vaccination status of all patients should be assessed at every health care visit to reduce missed opportunities for vaccination. Use of standing orders may further improve efficiency of catch-up vaccination.

To view this CDC communication in its’ entirety, visit https://www.cdc.gov/vaccines/pandemic-guidance/index.html.NJ-NL-0442-20

Page 3 of 8

Medicaid

Patient360

Quickly retrieve detailed records about your Amerigroup Community Care patients through our provider self-service website using Patient360. This real-time dashboard gives you a robust picture of a patient’s health and treatment history and will help you facilitate care coordination. Access is through the secure provider portal at www.availity.com.*

Features of this tool allow you to: � Immediately retrieve a complete medical history

for new patients. � Spot utilization and pharmacy patterns. � Identify care gaps and trends. � Coordinate care more effectively.

NJPEC-0180-18

Medtox testing for blood lead levels

You have options to try and improve lead screening compliance with your patients. Medtox testing is a means of measuring blood lead levels using a capillary (finger stick) blood sample and filter paper in the office.

For additional information, call 1-800-832-3244 or visit: https://www.medtox.com/program-services/filter-paper-lead-testingNJ-NL-0338-19

Page 4 of 8

Prior authorization requirements for 0200T and 0201T

Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

To request PA: Web: https://www.availity.com* • Fax: 1-800-964-3627 • Phone: 1-800-454-3730

Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://providers.amerigroup.com/NJ > Login. Contracted and noncontracted providers who are unable to access Availity may call Provider Services at 1-800-454-3730 for assistance with PA requirements.

* Availity, LLC is an independent company providing administrative support services on behalf of Amerigroup Community Care.

Effective September 1, 2020, prior authorization (PA) requirements will change for 0200T and 0201T. The medical codes listed below will require PA for Amerigroup Community Care members.

PA requirements will be added to the following: � 0200T — Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a

balloon or mechanical device, when used, one or more needles � 0201T — Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a

balloon or mechanical device, when used, two or more needles

NJ-NL-0427-20

Medical drug Clinical Criteria updates

May 2020 updateOn May 15, 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.

Effective dates are reflected in the Clinical Criteria web posting.NJ-NL-0425-20

The Clinical Criteria is publicly available on our provider website. Visit Clinical Criteria to search for specific policies.

Please submit your questions to email.

Page 5 of 8

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

To view a guideline, visit https://medicalpolicies.amerigroup.com/am_search.html.

Notes/updates:Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

� CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

� Expanded scope of document and revised Medically Necessary statement

� CG-DME-47 — Noninvasive Home Ventilator Therapy for Respiratory Failure

� Revised Medically Necessary and Discussion/General Information sections

� CG-GENE-02 — Analysis of RAS Status � Clarified scope of document and revised

the Not Medically Necessary and Coding sections

� CG-MED-64 — Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)

� Revised the Medically Necessary statement � CG-MED-68 — Therapeutic Apheresis

� Revised Medically Necessary, Not Medically Necessary, Coding and Discussion/General Information sections

� DME.00011 — Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

� Revised Investigational and Not Medically Necessary, Rationale and Coding sections

� MED.00004 — Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

� Revised the Not Medically Necessary, Rationale and Coding sections

Medical Policies On November 7, 2019, February 20, 2020, and May 14, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup Community Care. View the update online for a list of the policies.

Clinical UM Guidelines On November 7, 2019, February 20, 2020, and May 14, 2020, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. These guidelines were adopted by the medical operations committee for Amerigroup members on on November 28, 2019, April 23, 2020, and May 25, 2020. View the update online for a list of the guidelines.

Read more online.

NJ-NL-0429-20

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Coverage provided by Amerigroup Inc.

Medicare Advantage

Medicare Advantage

Medical drug Clinical Criteria updates

May 2020 updateOn May 15, 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.

Effective dates are reflected in the Clinical Criteria web posting.AGPCRNL-0124-20

The Clinical Criteria is publicly available on our provider website. Visit Clinical Criteria to search for specific policies.

Please submit your questions to email.

Page 7 of 8

Update: Notice of changes to the AIM musculoskeletal program

As you know, AIM Specialty Health® (AIM)* administers the musculoskeletal program for Medicare Advantage members, which includes the medical necessity review of certain surgeries of the spine, joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care.

Effective December 1, 2021, two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM guideline, it is generally appropriate to perform these two procedures in a hospital outpatient setting. To avoid additional clinical review for these surgeries, providers requesting prior authorization should either choose hospital observation admission as the site of service or Hospital Outpatient Department (HOPD).

We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

� Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.

� Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.

On January 1, 2020, CMS removed total hip arthroplasty as well as six spine codes from the inpatient only (IPO) list making these procedures eligible for payment by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting. The two-midnight rule should guide providers on the expected reimbursement. The codes that were removed from the inpatient only list and are also in the AIM Musculoskeletal program are 27130, 22633, 22634, 63265 and 63267. CMS has established a two year grace period (ending December 31, 2021) for site of service reviews of these codes in order to facilitate provider transition to compliance with the two-midnight rule. To this end, it is recommended that providers choose hospital observation or Hospital Outpatient Department (HOPD) during the prior authorization process when clinically appropriate to the respective patient. Choosing hospital observation still allows for the surgery to be performed and recovered in the main hospital, so long as discharge is planned for less than two midnights. Alternatively, the provider may choose to perform the procedure in the Hospital Outpatient Department (HOPD). However, the inpatient setting will still be approved should the provider decide it is the optimal setting for the member.

Providers should continue to submit prior authorization requests to AIM using one of the following ways:

� Access AIM ProviderPortalSM directly at http://providerportal.com. 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* at http://www.availity.com. � Call the AIM toll-free number at 1-800-714-0400, Monday through Friday 8 a.m. to 8 p.m. ET.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Amerigroup Community Care. Availity, LLC is and independent company providing administrative support services on behalf of Amerigroup Community Care.AGPCRNL-0125-20

Page 8 of 8

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

To view a guideline, visit https://medicalpolicies.amerigroup.com/am_search.html.

Notes/updates:Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

� CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

� Expanded scope of document and revised Medically Necessary statement

� CG-DME-47 — Noninvasive Home Ventilator Therapy for Respiratory Failure

� Revised Medically Necessary and Discussion/General Information sections

� CG-GENE-02 — Analysis of RAS Status � Clarified scope of document and revised

the Not Medically Necessary and Coding sections

� CG-MED-64 — Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)

� Revised the Medically Necessary statement � CG-MED-68 — Therapeutic Apheresis

� Revised Medically Necessary, Not Medically Necessary, Coding and Discussion/General Information sections

� DME.00011 — Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

� Revised Investigational and Not Medically Necessary, Rationale and Coding sections

� MED.00004 — Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)

� Revised the Not Medically Necessary, Rationale and Coding sections

Medical Policies On November 7, 2019, February 20, 2020, and May 14, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup Community Care. View the update online for a list of the policies.

Clinical UM Guidelines On November 7, 2019, February 20, 2020, and May 14, 2020, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. These guidelines were adopted by the medical operations committee for Amerigroup members on on November 28, 2019, April 23, 2020, and May 25, 2020. View the update online for a list of the guidelines.

Read more online.

AGPCRNL-0127-20