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Provider Newsletter

October 2018NJ-NL-0192-18

October 2018

Table of ContentsMedicaid:Personal care services rate increase due to state-mandated Medicaid rates Page 2

What Matters Most: Improving the Patient Experience CME Page 2

National Health Care Center week Page 2

EDI Gateway migration Page 3

Interactive Care Reviewer tool Page 3

Patient360 Page 3

PCPs should assist members to establish a dental home Page 4

A care team approach for diabetes management Page 5

Coding spotlight: substance use disorders and smoking Page 6

Vaginal birth after cesarean shared decision-making aid available Page 6

Cervical length measurement by transvaginal ultrasound Page 6

Childhood vaccinations Page 7

Its flu season — Be sure your patients are vaccinated Page 8

Gaps in Care Reports Page 8

The importance of care coordination in health care delivery Page 9

Medical Policies and Clinical Utilization Management Guidelines updates

Page 10

Prior authorization requirements Page 10

Amerivantage:EDI Gateway migration Page 12

Prior authorization requirements Page 12

Page 2 of 13

Medicaid

Personal care services rate increase due to state-mandated Medicaid rates

Pursuant to PL 2017, c 237 1, the Medicaid managed care reimbursement rate for personal care services (PCS) is mandated to be at least the minimum state Medicaid fee-for-service hourly rate established by law as of July 1, 2018. Amerigroup Community Care has updated our fee schedules accordingly to ensure compliance with the new law. Effective July 1, 2018, you should have begun to receive the mandated rate increase for PCS when billing an amount greater than or equal to the minimum state rate.

What is the impact of this change?The hourly rate for PCS (T1019) increased to match the minimum state Medicaid fee-for-service rate effective July 1, 2018. In accordance with the law, funds received as a result of this increased rate must be used exclusively for salary increases for workers who directly provide PCS. Further, you are required to submit an annual report detailing the use of the increased reimbursement to the Division of Medical Assistance and Health Services.

A PCS provider’s billed charges must be greater than or equal to the minimum state Medicaid fee-for-service rate to be paid in accordance with the legislation. NJPEC-1542-18

What Matters Most: Improving the Patient Experience CME

Are you looking for innovative ways to improve your patients’ experiences?Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions. Recently, Amerigroup Community Care announced the launch of a new online learning course —What Matters Most: Improving the Patient Experience — to address gaps in and offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide.

For more information on What Matters Most: Improving the Patient Experience, check out the full Provider Update on our website.NJ-NL-0190-18

National Health Care Center week

Amerigroup Community Care was proud to participate in close to 30 events during this year’s National Health Center Week held August 12-18. National Health Care Week is held annually with the goal of raising awareness about the mission and accomplishments of America’s federally qualified health centers. Themes at the various events included Superheroes, Back to School and Health and Wellness. Amerigroup representatives provided health education on sun safety and nutrition as well as assistance with NJ FamilyCare enrollment and redetermination.NJPEC-0183-18

Page 3 of 13

The 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.

EDI Gateway migration

Amerigroup Community Care has partnered with Availity to become our designated EDI Gateway effective January 1, 2019.

What does this mean to you as a provider?All EDI submissions currently received are now available on Availity. Please note, there is no impact to provider participation statuses and no impact on how claims adjudicate.

Next stepsContact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you — You can submit claims directly through Availity!

Register with AvailityIf you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

If you have any questions please contact Availity Client Services at 1-800-282-4548, Monday through Friday, 8 a.m.-7:30 p.m. Eastern time NJ-NL-0187-18

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 https://www.availity.com.

Interactive Care Reviewer tool

ICR is a secure, online provider utilization management tool — accessed via the Availity Portal — that offers a streamlined process to request authorization of inpatient and outpatient procedures/services. With this tool, your practice can initiate online medical and behavioral health preauthorization requests for Amerigroup Community Care members more efficiently and conveniently as well as locate information on previously submitted requests.

Register at https://www.availity.com.

Select Authorization and Referral Request or Authorization and Referral Inquiry.

� Determine if preauthorization is required. � Receive viewable decision letters. � Review the status of requests. � Save favorites: 25 requesting providers, 25

servicing providers, 25 facility/DME providers, and 25 referral providers.

For assistance, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548), Monday through Friday 8 a.m.-7 p.m. Eastern Time.

ICR is not currently available for requests involving transplant services or services administered by AIM Specialty Health® or OrthoNet LLC. For these, contact Provider Services (1-800-454-3730) or follow the same PA process you use today.NJPEC-0179-18

NJPEC-0180-18

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PCPs should assist members to establish a dental home

Effective July 1, 2018, Liberty Dental Plan became the new dental vendor for Amerigroup Community Care. Search for primary care dentists at www.libertydentalplan.com/AmerigroupNJ or contact Liberty Dental Plan at 1-833-276-0848 (TTY 711), Monday-Friday, 8 a.m.-8 p.m. for assistance.

According to the American Academy of Pediatrics (AAP), Dental caries — or tooth decay — is the most common chronic disease in children in the U.S. Dental caries a silent disease that disproportionally affects poor, young and minority populations.

Although PCPs have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home.

Here’s what you can do: � Partner with a primary care dentist in the

Liberty Dental network for patient referrals. � Refer your child patients to be seen by a dentist

when the first tooth appears and no later than his/her first birthday.

� Complete the AAP Oral Health Risk Assessment Tool for children under age 6 or the ADA Caries Risk Assessment Form for ages 6 and up. Both forms are available online.

� Prescribe a fluoride supplement (drops, tablets or lozenges) to children whose water supply does not have enough fluoride.

� Fluoride varnish applications can be provided in the primary care setting by trained NJ Smiles providers every three-six months or up to four times a year, starting at tooth emergence through age 6. The PCP fluoride varnish application does not constitute a dental visit.

� Discuss risk factors for tooth decay and preventative measures to practice good oral hygiene, seek oral health care and to prevent transmission of caries-causing bacteria to infants and children

� Educate family members to minimize exposure to natural or refined sugars in foods that can lead to dental caries and to establish lifelong nutritious eating patterns with infants and children.

� Check in with your patient at the next office visit to ensure that they are seeing a primary care dentist on a regular basis.

Dental services coverage: � Covered services are provided through Liberty

Dental Plan and include diagnostic and preventive services (e.g., exams, cleanings and space maintainers) and restorative services.

� Sealants and sealant repairs are covered for bicuspids and permanent molars once every three years for members under age 17 and is covered with Prior Authorization (PA) for members with special health care needs.

� PA is required for endodontic, periodontic, prosthodontic services, and oral maxillofacial medical and surgical conditions, including TMJ, and services for trauma of the teeth.

� Dental Implants associated with retaining complete dentures are covered when medically necessary and with PA.

� Orthodontic services are covered when medically necessary through age 18 with PA. Medical necessary conditions include major functional problems such as facial trauma, developmental differences of facial bones and/or oral structures, and long-term physiological health needs.

References:1. https://www.aap.org/en-us/about-the-aap/aap-press-room/

Pages/AAP-Recommends-Fluoride-to-Prevent-Dental-Caries.aspx

2. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/dental-caries-in-children-from-birth-through-age-5-years-screening

3. https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_OralHealth.pdf

4. https://www.libertydentalplan.com/Resources/Documents/AAP%20Oral%20Health%20Risk%20Assessment%20Tool.pdfNJ-NL-0181-18

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A care team approach for diabetes management

A successful medical evaluation of patients with diabetes depends on beneficial interactions between the patient and the care team. The care team should aim to take an active role in the patient’s care by creating a lifestyle management plan that includes physical activity, healthy eating, coping skills and the support of family and/or other persons. This interdisciplinary team includes the primary care provider, ophthalmologist, dentist, podiatrist, pharmacist, dietician and behavioral health providers if needed.

Here’s what you can do to provide high-level care to patients with diabetes: � Emphasize the importance of metabolic control and the control of other cardiovascular risk factors

including high blood pressure, cholesterol and smoking cessation. � Assess social context including food insecurity, housing stability and financial barriers, and then

apply this information to treatment decisions. � Provide self-management supports from health coaches, navigators or community health workers. � Recommend routine checkups to prevent complications: dental exam, comprehensive foot exam,

HbA1c testing and a complete dilated eye exam. � Follow up to ensure patient compliance with specialty care and routine specialist checkups. � Refer noncompliant members for potential case management services. � If your practice uses EMRs, have flags or reminders set in the system to alert your staff when a

patient’s screenings are due. � Send appointment reminders and call members to remind them of upcoming appointments and

necessary screenings.

The American Diabetes Association offers continuing education programs including “Diabetes Is Primary” where primary care providers can earn 6 CME credits. Visit https://professional.diabetes.org/diabetes-primary for more information.

Remember to include the applicable Category II reporting codes to help reduce the burden of HEDIS medical record review.

Here’s how Amerigroup can help: � Offer case management services to eligible members. � Supply copies of educational resources on diabetes for your office. � Provide diabetes educational workshops at your office for all of our patients and your staff.

Sources:1. https://professional.diabetes.org/content-page/standards-medical-care-diabetes 2. https://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide-team-care-approach.pdf https://www.cdc.gov/dhdsp/programs/spha/

docs/abcs_guide.pdf

3. http://care.diabetesjournals.org/content/41/Supplement_1/S28NJ-NL-0178-18

Page 6 of 13

Coding spotlight: substance use disorders and smoking

Drug addiction or substance use disorder affects a person’s brain and in turn their behavior. Substance addiction can start with the experimental use of a drug in a social situation or with exposure to prescribed medications. Eventually it leads to an inability to control the use of the legal or illegal drug or medication. When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations and comorbidities. This article aims to equip you with

the information you need to provide high-quality care to patients struggling with substance use as well as how to code for the services provided to them.

For detailed information on substance use disorders and smoking including health risks, diagnosis and treatment, HEDIS® quality measures related to substance use, and coding information, please view the full update on our provider website.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).NJ-NL-0176-18

Cervical length measurement by transvaginal ultrasound

In our efforts to improve pregnancy outcomes, including the prevention of preterm birth, Amerigroup Community Care previously communicated our endorsement of the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) guidelines on cervical length (CL) screening and progesterone treatment.

We continue to encourage you to obtain a CL measurement with your patient’s routine prenatal anatomic evaluation ultrasound. For claims submitted on or after January 1, 2019, if a vaginal approach is necessary in addition to an abdominal scan to obtain this measurement, the transvaginal ultrasound will be considered for a multiple procedure reduction.

What is the impact of this change? When a routine anatomic evaluation ultrasound (76801, 76802, 76805, 76810) and a transvaginal ultrasound (76817) are billed on the same day by the same provider, the transvaginal ultrasound is considered a part of the multiple procedure payment reduction policy and will be paid at 50 percent of the applicable fee schedule, and the complete procedure will be paid at the full applicable fee schedule.NJPEC-2075-18

Vaginal birth after cesarean shared decision-making aid available

As part of our commitment to provide you with the latest clinical information, we have posted a vaginal birth after cesarean (VBAC) shared decision making aid to our provider site. This tool has been reviewed and certified by the Washington Health Care Authority* and is available to aid in discussions with your patients regarding their treatment options.

* The Washington Health Care Authority is recognized as a certifying body by NCQA.NJ-NL-0172-18

Page 7 of 13

Childhood vaccinations

The Centers for Disease Control and Prevention (CDC) recommends yearly vaccination for anyone 6 months and older including even the healthiest adults. The CDC vaccine schedule for children is carefully timed to provide protection when children are most vulnerable and when the vaccines will produce the strongest response from the child's immune system.

The childhood immunization combination 10 HEDIS measure evaluates member ages 2 years and younger who received the following vaccinations before their second birthday: DTap, IPV, MMR, Hib, Hep B, VZV, PCV, Hep A, Rotavirus and influenza. The adolescent immunization HEDIS® measure evaluates children and adolescents who received the following immunizations by their 13th birthday: Meningococcal, Tdap and HPV (male and female).

To view the suggested vaccine schedule, see page 10 of the Preventive Health Guidelines.

The Preventative Health Guidelines are located on the provider website under the heading Clinical Practice Guidelines.

Here’s what you can do: � If you use an EMR, create a flag to track

members due for immunizations. � Develop or implement standing orders

for nurses and physician assistants in your practice to allow staff to identify opportunities to immunize.

� Consider accommodating working parents by offering extended office hours

Here’s how Amerigroup can help: � We can provide you with individual reports

of your members due for services. � We may be able to assist with patient

scheduling. � Clinical Practice Guidelines are listed on our

website. � Our booklet, HEDIS Benchmarks and Coding

Guidelines for Quality Care, is available for reference.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

References:1. http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2017-table-of-contents/childhood-immunization-

status2. https://www.healthychildren.org/English/news/Pages/2018-Childhood-and-Adolescent-Immunization-Schedules-Released.aspx3. https://providers.amerigroup.com/ProviderDocuments/NJNJ_CAID_2017PreventiveHeatlhGuide.pdfNJPEC-0185-18

Page 8 of 13

Its flu season — Be sure your patients are vaccinated

Children younger than 5 years and especially those younger than 2 years are at high risk of serious influenza complications. The American Academy of Pediatrics (AAP) reports that each year, on average, 5-20 percent of the U.S. population gets the flu and more than 200,000 people are hospitalized from complications. The Centers for Disease Control and Prevention (CDC) reported 178 flu-related deaths in children during 2017-2018.

Providers should offer influenza vaccine routinely, and organized vaccination campaigns should continue throughout the influenza season, including after influenza activity has begun in the community.

The CDC advises that although vaccination by the end of October is recommended, vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons.

Vaccination is especially important for people who are at high risk of serious influenza complications or that live with or care for people at higher risk for serious complications.

Because pregnant and postpartum women are at higher risk for severe illness and complications from influenza, all women who are pregnant or who might be pregnant in the upcoming influenza season should be vaccinated. Influenza vaccination can be administered at any time during pregnancy. Vaccination helps protect women during and after pregnancy. Getting vaccinated can also protect a baby after birth from flu.

People who are moderately or severely ill with or without fever should usually wait until they recover before getting flu vaccine.

References:1. https://www.cdc.gov/flu/index.htm

2. https://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/The-Flu.aspx NJPEC-0186-18

Gaps in Care Reports

We are pleased to announce that Gaps in Care Reports are now available. These reports are produced on a quarterly basis to provide PCP practices with a list of panel members and each HEDIS® measure where a care gap (administrative, based on claim history) has been identified.

Quality Measures desktop Reference for Medicare and Medicaid Providers is available on the provider website under Quality Management. To request a copy of the Amerigroup Community Care annual HEDIS Benchmarks and Coding Guidelines for Quality Care, please contact your Network Management Representative or the Quality Management department at 1-877-453-4080, option 1.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).NJPEC-0182-18

Page 9 of 13

The importance of care coordination in health care delivery

When patients get care, they often interact with multiple health care professionals across multiple settings. When health care professionals don’t coordinate with each other, consequences leading to low quality care or worse health outcomes may occur. Navigating health care can be confusing for anyone but this can be particularly difficult for those with chronic conditions. Uninformed medical professionals may grapple with being able to understand the patient’s medical history in order to understand symptoms and develop effective treatment plans.

Care coordination is health care that is delivered in a planned way that meets the needs and preferences of the patient by coordinating care with physicians, physician extenders, nurses, pharmacists, dentists, behavioral health providers, and other health care professionals, community-based resources and the health plan to improve health outcomes.

The care coordinator is often the patient’s primary care provider but, depending on the patient’s unique health care needs, may be a specialty care provider or other health care professional.

The PCP or other Care Coordinator is responsible for: � Engaging the patient (and his caregiver, if appropriate) in the development of an individualized care plan

that reflects his health care needs and priorities � Keeping an open dialogue with the patient to ensure that she understands her role in the care plan and

feels equipped to fulfill her responsibilities � Anticipating care needs and ensuring that routine screenings are performed when they are due � Identifying psychological, social, financial and environmental barriers that can affect the patient’s ability

to adhere to treatments or maintain his health � Assembling the appropriate team of health care professionals to address the patient’s needs � Recognizing when a patient has a co-occurring physical or behavioral health care need that should be

addressed by another health care professional � Providing clear communication to the patient when coordinating care with other health professionals

about the need for referral and what to do after seeing the provider � Coordinating treatment, especially medication management, with other physical and behavioral health

providers throughout the course of treatment � Sharing of information with other health care professionals and ensuring that the patient’s medical

record reflects the most up-to-date information and is accessible to all care team members � Following up with the patient periodically to ensure his needs are being met and that his circumstances

and priorities have not changed

The deliberate organization of patient care activities and sharing of information among all of the participants concerned with a patient's care results in safer and cost effective quality care that will optimally manage health conditions and can reduce the need for unnecessary or duplicative medical services, emergency room visits, and hospitalizations.

References:1. https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html2. http://integrationacademy.ahrq.gov3. https://familiesusa.org/sites/default/files/product_documents/Care-Coordination.pdfNJPEC-0184-18

Page 10 of 13

Prior authorization (PA) requirements

Somatrem

Effective December 1, 2018, PA requirements will change for injectable/infusible drug Somatrem to be covered by Amerigroup Community Care for Medicaid members.

PA requirements will be added to the following:

� Somatrem — injection, 1 mg (J2940)NJ-NL-0175-18

Interferon beta-1a

Effective December 1, 2018, PA requirements will change for injectable/infusible drug Interferon beta-1a to be covered by Amerigroup Community Care for Medicaid members.

PA requirements will be added to the following:

� Interferon beta-1a — injection, 30 mcg (J1826)NJ-NL-0174-18

Medical Policies and Clinical Utilization Management Guidelines updates

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.

Note: � Effective November 1, 2018, AIM Specialty Health® Proton Beam Therapy will be

used for clinical reviews.

Please share this notice with other members of your practice and office staff.

To search for specific policies or guidelines, visit https://medicalpolicies.amerigroup.com/search.

Medical PoliciesOn May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup Community Care.

Clinical UM Guidelines On May 3, 2018, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. The update details the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

View the list of newly approved Medical Policies and Clinical UM Guidelines in the May 2018 udpate.

NJ-NL-0170-18

Page 11 of 13

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, you may use one of the following methods: � Web: https://www.availity.com � Fax: 1-800-964-3627 � Phone: 1-800-454-3730

Not all PA requirements are listed here. Detailed PA requirements are available to contracted and noncontracted providers on our provider website (https://providers.amerigroup.com/NJ > Proider Resources & Documents > Quick Tools > Precertification Lookup Tool). Providers may also call us at 1-800-454-3730 for PA requirements.

PA requirements (cont.)

High-level, definitive drug testing

Effective December 1, 2018, PA requirements will change for high-level, definitive drug testing(s). The high-level, definitive drug testing(s) will require PA for Amerigroup Community Care members.

PA requirements will be added to the following: � G0482 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual

drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, gas chromatography/mass spectrometry (GC/MS) (any type, single or tandem) and liquid chromatography/mass spectrometry (LC/MS) (any type, single or tandem and excluding immunoassays; e.g., immunoassays [IA]; enzyme immunoassay [EIA]; enzyme-linked immunosorbent assay [ELISA]; enzyme multiplied immunoassay technique [EMIT]; fluorescence polarization immunoassay [FPIA]; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es) including metabolite(s) if performed.

� G0483 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays; e.g., IA; EIA; ELISA; EMIT; FPIA; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es) including metabolite(s) if performed.

NJPEC-2092-18

Page 12 of 13

Coverage provided by Amerigroup Inc.

Amerivantage

What does this mean to you as a provider?All EDI submissions currently received are now available on Availity. Please note, there is no impact to provider participation statuses and no impact on how claims adjudicate.

Next stepsContact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you — You can submit claims directly through Availity!

EDI Gateway migration

Amerigroup Community Care has partnered with Availity to become our designated EDI Gateway effective January 1, 2019.

Prior authorization (PA) requirements

Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila (pegfilgrastim-jmbd)

Effective December 1, 2018, PA requirements will change for Part B injectable/infusible drugs Moxetumomab Pasudotox, Cemiplimab and Fulphila (pegfilgrastim-jmbd) to be covered by Amerigroup Community Care for D-SNP members.

PA requirements will be added to the following: � Moxetumomab pasudotox — for treatment of relapsed or refractory hairy cell leukemia in patients who

have received at least two prior lines of therapy (J3590, J9999) � Cemiplimab — PD-1 inhibitor for the treatment of patients with metastatic cutaneous squamous cell

carcinoma (CSCC) or patients with locally advanced CSCC who are not eligible for surgery (J3590, J9999) � Fulphila (pegfilgrastim-jmbd) — a biosimilar to Neulasta approved for febrile neutropenia in patients with

chemotherapy in certain types of cancer (J3490, J3590)

Please note, one or more of the drugs noted above are currently billed under the not otherwise classified (NOC) HCPCS J-codes J3490, J3590 and J9999. Since these codes include all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS code.NJ-NL-0173-18

Register with AvailityIf you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

If you have any questions, please contact Availity Client Services at 1-800-282-4548, Monday through Friday, 8 a.m.-7:30 p.m. Eastern time. SSO-NL-0048-18

Page 13 of 13

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, you may use one of the following methods: � Web: https://www.availity.com � Fax: 1-844-765-5160 � Phone: 1-844-799-4129

Not all PA requirements are listed here. Detailed PA requirements are available to contracted and noncontracted providers on our provider website (https://providers.amerigroup.com/NJ > Proider Resources & Documents > Quick Tools > Precertification Lookup Tool). Providers may also call us at 1-844-799-4129 for PA requirements.

PA requirements (cont.)

High-level, definitive drug testing

Effective December 1, 2018, PA requirements will change for high-level, definitive drug testing(s). The high-level, definitive drug testing(s) will require PA for Amerigroup Community Care members.

PA requirements will be added to the following: � G0482 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual

drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, gas chromatography/mass spectrometry (GC/MS) (any type, single or tandem) and liquid chromatography/mass spectrometry (LC/MS) (any type, single or tandem and excluding immunoassays; e.g., immunoassays [IA]; enzyme immunoassay [EIA]; enzyme-linked immunosorbent assay [ELISA]; enzyme multiplied immunoassay technique [EMIT]; fluorescence polarization immunoassay [FPIA]; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es) including metabolite(s) if performed.

� G0483 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays; e.g., IA; EIA; ELISA; EMIT; FPIA; and enzymatic methods [e.g., alcohol dehydrogenase]); (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength); and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es) including metabolite(s) if performed.

NJPEC-2092-18