sm september 2015 · 2019-10-11 · procedure coding system (hcpcs) codes will continue to be used...

updateSM

Preparing for the upcoming October 1, 2015, ICD-10 compliance date page 3

Changes coming in mid-September to NaviNet® page 11

Migration of AmeriHealth New Jersey commercial members begins September 1, 2015 page 4

September 2015

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2015 www.dreamstime.com. All rights reserved.

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

The third-party websites mentioned in this publication are maintained by organizations over which AmeriHealth exercises no control, and accordingly, AmeriHealth disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.

NaviNet is a registered trademark of NaviNet, Inc.

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

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

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

Contact information:Provider CommunicationsAmeriHealth1901 Market Street 27th FloorPhiladelphia, PA 19103

[email protected]

Inside this edition

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

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

Professional Facility Ancillary

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

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

ICD-10 ► Preparing for the upcoming October 1, 2015, ICD-10

compliance date

Administrative ► Migration of AmeriHealth New Jersey commercial members

begins September 1, 2015 ► Interpreting your PCP payments via EFT ► An updated provider appeals form now available ● Reminder: Medicare Advantage members must use designated

site for capitated services

Billing ► Professional Injectable and Vaccine Fee Schedule updates

effective October 1, 2015 ► Medical Nutrition Therapy coverage for Medicare Advantage

members

NaviNet®

► Changes coming in mid-September to NaviNet®

Medical ► Chiropractic services policy update ► View up-to-date policy activity on our Medical Policy Portal ► Annual Synagis® (palivizumab) distribution program approaches ● Reminder: Coverage for injectable drugs that reduce the risk of

preterm birth

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

Health and Wellness ● Let’s Go See initiative raises awareness of vision problems in

children ● Suicide: A concern for all health care providers:

Part 3 – After screening/assessing: How to assure safety of the person who is at risk for suicide

ICD-10

September 2015 | Partners in Health UpdateSM 3 www.amerihealth.com

Preparing for the upcoming October 1, 2015, ICD-10 compliance date On October 1, 2015, the United States will transition from ICD-9 to ICD-10 as the medical code set for medical diagnoses and inpatient hospital procedures. The transition to ICD-10 is not just an update but rather a complete overhaul. Our entire industry – payers, providers, and vendors – is affected by the transition to the expanded ICD-10 code set. These coding changes will affect medical coding operations, software systems, reporting, administration, registration, and more. Any delay could result in your office or organization experiencing backlogs, denials, and impacts on revenue.

As we rapidly approach the October 1, 2015, compliance deadline, we encourage you to plan ahead and be fully aware of all of the changes that will occur with the implementation of ICD-10. If you do not use valid ICD-10 codes for dates of service or dates of discharge on or after October 1, 2015, you will not be able to successfully bill for your services. Also note that our claims processing system will not accept both ICD-9 and ICD-10 codes on a single claim.

Now is the time to make sure your office is ICD-10 ready. The transition will go much more smoothly for organizations that have planned ahead. A successful transition to ICD-10 will be vital to transforming our nation’s health care system and ensuring uninterrupted operations.

Please also be aware that Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes will continue to be used for outpatient, ambulatory, and office-based procedure coding.

Claims for services that span the compliance dateClaims submitted for a date of service or date of discharge (for facility inpatient claims) on or after October 1, 2015, are required to be submitted with valid ICD-10 codes.

If your office submits an ICD-9 code on or after the October 1, 2015, compliance date, your claim will be denied and sent back to you for compliant coding. Providers should work with their trading partners, clearinghouses, and billing vendors/billing software companies to ensure ICD-10 compliance and avoid claims rejections, processing delays, and revenue impacts.

Additionally, all authorization and referral requests submitted prior to and including September 30, 2015, are required to use ICD-9 codes. All authorization and referral requests submitted on or after October 1, 2015, are required to use ICD-10 codes.

Provider resourcesTo help you prepare, we encourage you to take advantage of the resources available through AmeriHealth and the Centers for Medicare & Medicaid Services (CMS).

● Provider News Center: www.amerihealth.com/pnc ● NaviNet® Plan Central: www.navinet.net

AmeriHealth Pennsylvania resources ● ICD-10 web page: www.amerihealth.com/icd10 ● Frequently asked questions: www.amerihealth.com/pdfs/providers/claims_and_billing/icd_10/icd_10_faq.pdf

AmeriHealth New Jersey resources ● ICD-10 web page: www.amerihealthnj.com/html/providers/claims_billing/coding.html

● Frequently asked questions: www.amerihealthnj.com/Resources/pdfs/7.3/icd_10_faq.pdf

CMS resources ● ICD-10 web page: www.cms.gov/ICD10 ● Road to 10: The Small Physician Practice’s Route to ICD-10: www.roadto10.org

● Provider Resources: www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

ATTENTION: After the October 1, 2015, compliance date, we encourage you to closely monitor your

Health Care Claim Acknowledgement (277CA) transactions, Provider Explanation of Benefits (Provider EOB), and/or Provider Remittance to quickly identify and address coding issues related

to ICD-10. If the incorrect code set is submitted after the compliance date, your claim will be denied and sent back to you for proper coding.

www.amerihealth.com/pdfs/providers/claims_and_billing/icd_10/icd_10_faq.pdf

www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

www.amerihealthnj.com/html/providers/claims_billing/coding.html

www.amerihealthnj.com/Resources/pdfs/7.3/icd_10_faq.pdf

ADMINISTRATIVE


Migration of AmeriHealth New Jersey commercial members begins September 1, 2015As previously communicated, the migration of AmeriHealth New Jersey commercial members to the new operating platform begins on September 1, 2015. The migration will occur in two waves: some groups will transition on September 1, 2015, and the remaining AmeriHealth New Jersey commercial members will transition on October 1, 2015. We expect all AmeriHealth members (i.e., Pennsylvania, New Jersey, commercial, and Medicare Advantage) to be on the new platform as of October 1, 2015.

During the migration, we will be working with you in a dual claims-processing environment until all AmeriHealth New Jersey commercial members are migrated to the new platform on October 1. The date of service will determine the platform on which these claims will be processed.

This article summarizes the important changes that we have communicated this year that will affect the way you do business both during and following the migration.

Members issued new ID cardsMembers will be issued a new ID card upon migration. ID cards for migrated members differ from non-migrated member ID cards in the following ways:

● AmeriHealth will assign a new 12-digit member ID number, called a “unique member ID” (UMI). ● The subscriber and all members covered under the subscriber’s policy will share the same ID number. Each member ID card will include the member’s name and subscriber UMI.

● AmeriHealth New Jersey commercial member ID cards will now indicate in which network the member is enrolled. The AmeriHealth New Jersey network indicator will be located on the top right section of the card, including designations such as Local Value and Regional Preferred. If the AmeriHealth New Jersey commercial member is enrolled in the National Access network through Private Healthcare Systems, Inc. (PHCS), the logo will also be included on the bottom right of the ID card.

It is imperative that provider offices do the following: ● obtain a copy of the member’s ID card at every visit to ensure that you submit the most up-to-date information to AmeriHealth;

● verify eligibility and benefits using the NaviNet® web portal prior to rendering service.

Below are several sample ID cards for migrated members:

continued on the next page

ADMINISTRATIVE


Claim submission requirements The use of a valid National Provider Identifier (NPI) and taxonomy codes are required on all migrated member claims to ensure proper claims processing.

Valid NPIIt is critical that you submit all claims with a valid NPI. The new claims processing system reviews each claim for this data. Providers should work with their clearinghouse/trading partner to ensure accurate claims submission.

The most common reasons that an NPI would be considered invalid are: ● The NPI is terminated. ● The NPI is entered incorrectly. ● The number is invalid.

Using an invalid NPI could delay processing and payment. For additional information about NPI regulations, implementations, reports, and resources, go to www.amerihealthnj.com/html/providers/claims_billing/npi.html.

Taxonomy codesIf your group NPI is associated with more than one AmeriHealth specialty, you must include the appropriate provider taxonomy code in addition to the NPI on all claims. This allows the accurate application of the provider’s contractual business arrangements with AmeriHealth. Failure to submit claims with the applicable NPI and correct correlating taxonomy code may result in incorrect claims processing and/or payment delays.

Refer to the article, Guidelines for billing with taxonomy codes and use of NPI on claims, in the August 2015 edition of Partners in Health Update for an illustration of how to correctly submit your taxonomy code.

Provider Automated System Once an AmeriHealth member is migrated to the new platform, you can no longer use the Provider Automated System for that member. Therefore, as of October 1, 2015, the Provider Automated System will no longer be available for any AmeriHealth members, as they will have all been migrated to the new platform. You must use NaviNet to retrieve information such as eligibility and benefits or claims status.

Provider paymentFor claims processed on the new platform, payments will be made weekly, as opposed to daily, for providers that bill an 837/UB claim type.

In addition, providers no longer receive a Statement of Remittance (SOR) for migrated members. Professional providers receive what is called the Provider Explanation of Benefits (EOB), and facility providers receive what is called the Provider Remittance. The Provider EOB and Provider Remittance have a new look and format from the former SOR. On the new format for facility claims, services are combined and displayed on one line.

Detailed guides for the Provider EOB and Provider Remittance are available in the Claims Submission and Payments section of the System and Process Changes site at www.amerihealth.com/pnc/changes. Terms are explained to assist you in interpreting your payment statements.

continued from the previous page


Once an AmeriHealth member is migrated to the new platform, you can no longer use the Provider Automated System for that member. Therefore, as of October 1, the Provider Automated System will no longer be available for any AmeriHealth members, as they will have all been migrated to the new platform.

Providers must use NaviNet to retrieve information such as eligibility and benefits or claims status.

ADMINISTRATIVE


NaviNet functionality changes for migrated membersThe following functionality on NaviNet is applicable only to migrated members; therefore, it will apply to AmeriHealth New Jersey commercial members upon migration:

● EOB and Remittance. Once a member has been migrated to the new platform, participating providers can use the EOB and Remittance transaction to get claim payment information for finalized claims processed on the new platform. Through this transaction, providers can download and/or print their Provider EOB or Provider Remittance for migrated members. Providers can also search for statements in two-week increments.

● Claims Investigation. For finalized migrated member claims, providers can utilize the Claim Investigation Inquiry transaction. This transaction allows providers to submit an adjustment for an individual claim and will permit limited claim editing (excluding the ability to submit late charges).

● Cap Rosters. If you are enabled for electronic funds transfer (EFT), you will no longer receive paper rosters/reports for AmeriHealth New Jersey commercial members once they are migrated to the new platform. Refer to the article, Interpreting your PCP payments via EFT, in this edition of Partners in Health Update for more information.

For more detailed information about using these transactions for migrated member claims, please refer to the article, NaviNet functionality will apply to New Jersey commercial members upon migration to the new platform, published in the June 2015 edition of Partners in Health Update.

Claims processing requirements Some differences in claims processing and outcomes will apply to AmeriHealth New Jersey commercial members upon migration:

● Multiple Surgical Reduction Guidelines. For professional providers, the calculation method used in applying Multiple Surgical Reduction Guidelines for migrated members is based on the procedure reported “Allowed Amount” and not the derived “Surgical Ranking,” which was used on the old platform. This may result in a different claim outcome. To review the policies that disclose the different calculations being used for the two platforms, refer to our Medical Policy Portal at www.amerihealth.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you’d like to view. Then type the policy name or number in the Search field: - Commercial: #11.00.10s: Multiple Surgical Reduction Guidelines - Medicare Advantage: #MA11.032b: Multiple Surgical Reduction Guidelines

● Clinical Relationship Logic. Clinical Relationship Logic, or Code-to-Code Edits (e.g., incidental, integral, component, mutually exclusive), applied to services reported on a CMS-1500 claim form or electronic equivalent may differ depending on whether the claim is processed on the old or new platform. Clinical Relationship Logic, which is based on national standards, is used for migrated claims and is available on the AmeriHealth New Jersey website at www.amerihealthnj.com/html/providers/claims_billing/clinical_relationship_logic.html. The McKesson ClaimCheck® product will not be used on the new platform.

In a recent analysis of rejection rates of migrated claims, we found some common reasons why claims are rejecting on the new platform. For detailed information about reasons for claim rejections, please refer to the article, Upcoming changes to claims processing requirements and enforcing these changes for AmeriHealth New Jersey members, published in the August 2015 edition of Partners in Health Update.

Resources We will continue to work closely with you and our entire provider network as we complete our platform transition. For more information related to this transition, please visit our dedicated System and Process Changes site at www.amerihealth.com/pnc/changes. On this site you will find a communication archive as well as frequently asked questions. If you still have questions after reviewing these resources, email us at [email protected].


mailto: [email protected]


ADMINISTRATIVE


Interpreting your PCP payments via EFTPrimary care physicians (PCP) currently receive two different forms of payment from AmeriHealth:

● electronic funds transfer (EFT) for EFT-enabled providers and for all members who have been migrated to the new operating platform;

● paper checks for non-EFT-enabled providers and for non-migrated AmeriHealth New Jersey commercial members.

As previously communicated, AmeriHealth New Jersey commercial members will be migrated to the new operating platform on September 1, 2015, and October 1, 2015. Therefore, PCP payments for AmeriHealth New Jersey commercial members will switch to EFT as they are migrated.

This article is intended to assist our PCPs in understanding how capitation (CAP) payments are made for migrated and non-migrated members using the NaviNet® web portal. Please note, the process described applies only to provider offices set up to receive EFT payments.

Distribution of your CAP paymentsThe process flow below outlines how CAP payments are distributed and how to access the payment information through NaviNet.

Accessing CAP rosters and payments through NaviNetFrom the AmeriHealth Workflows menu, select ePayment and then PCP CAP Rosters. Be sure to use the online roster to obtain the most up-to-date information.

Total CAP Payment Amount (NaviNet) $ 13,066.27

Paper Check Amount - $ 789.25

EFT CAP Payment for Migrated Members $ 12,277.02

Example CAP paymentCAP payments

Providers can search the PCP CAP Rosters transaction on NaviNet by office location

(if applicable) for migrated members.

The total CAP payment amount represents your payment for non-migrated and migrated members.

Subtract the paper check amount from the total CAP payment amount to obtain total EFT CAP

payment for migrated members.

Providers receive paper checks for CAP payments for non-migrated members.


ADMINISTRATIVE


Next you will see the PCP Cap Rosters screen, which allows you to search by month, provider (office location), or tax ID number. Once the appropriate information is entered, select Search.

The results that appear reflect member-level detail of your CAP payment for all members – both migrated and non-migrated. The total CAP payment amount is displayed within the Capitation Statement summary.

For more informationA user guide that describes the PCP CAP Rosters transaction in greater detail is available in the NaviNet Resources section of our Provider News Center at www.amerihealth.com/pnc/navinet. If you have any questions regarding NaviNet transactions, call the eBusiness Hotline at 215-640-7410 for providers in Pennsylvania and Delaware and at 609-662-2565 for providers in New Jersey.


An updated provider appeals form now available Our newly updated provider appeals form gives you the ability to email or fax us your appeal requests for AmeriHealth New Jersey members. With this update, the process should be quicker, as you no longer have to mail in the application — saving time, cost, and processing.

Download and complete the Health Care Provider Application to Appeal a Claims Determination form, located at www.amerihealthnj.com/html/providers/provider_forms.html. You can either email it to [email protected] or fax it to 609-662-2610. While providers may continue to mail in the application, we strongly encourage you to use the new email or fax option.

Please contact your Provider Partnership Associate if you have any questions.



ADMINISTRATIVE


Reminder: Medicare Advantage members must use designated site for capitated servicesAmeriHealth 65® HMO members are required to use their primary care physician’s (PCP) capitated (designated) site for certain services, such as laboratory. This article is a reminder that PCPs must refer AmeriHealth 65 HMO members to their capitated site for these services. In order for a member to receive these services at a location other than the PCP’s capitated site, Clinical Services must provide preapproval based on medical necessity.

To verify what services are capitated for an AmeriHealth 65 HMO member, use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal and select the Capitated Site Information link on the Eligibility and Benefits Details screen for that member.

For more information about capitated services, please refer to the Provider Manual for Participating Professional Providers.

BILLING

Professional Injectable and Vaccine Fee Schedule updates effective October 1, 2015 Effective October 1, 2015, we will implement a quarterly update to our Professional Injectable and Vaccine Fee Schedule for all contracted providers. These updates reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables.

Allowance Inquiry transactionTo look up the rate for a specific code, use the Allowance Inquiry transaction on the NaviNet® web portal. To do so, go to AmeriHealth NaviNet Plan Central, select Claim Inquiry and Maintenance from the AmeriHealth Workflows menu, and then select Allowance Inquiry. For step-by-step instructions on how to use this transaction, refer to the user guide available in the NaviNet Resources section of our Provider News Center at www.amerihealth.com/pnc/navinet.

Note: The Allowance Inquiry transaction returns current rates for professional providers only. The reimbursement rates that go into effect October 1, 2015, will be available through this transaction on or after this effective date. Provider payment allowances are for informational purposes only and are not a guarantee of payment.

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

BILLING


Medical Nutrition Therapy coverage for Medicare Advantage membersThe Medical Nutrition Therapy benefits for your AmeriHealth 65® NJ HMO and AmeriHealth 65® Preferred HMO Medicare Advantage patients changed on January 1, 2015. Please review the information below regarding eligibility and coverage limitations to avoid claim processing delays and/or denials.

Who is eligible?AmeriHealth 65 NJ HMO and AmeriHealth 65 Preferred HMO patients with a Medicare medical benefit Part B who meet at least one of the following conditions are eligible to receive coverage for Medical Nutrition Therapy services:

● diabetes ● renal (kidney) disease (but not on dialysis) ● have had a kidney transplant in the last 36 months (when therapy is ordered by a doctor)

Medical Nutrition Therapy services require a referral and must be performed by a registered dietician or nutrition professional who meets certain requirements. Services may include nutritional assessment, one-on-one counseling, and therapy services.

Limitations of coverageEligible Medicare Advantage HMO members are limited to the following benefits for Medical Nutrition Therapy per calendar year:

● three hours of one-on-one counseling during the first year of Medical Nutrition Therapy under their Medicare Advantage coverage;

● two hours of one-on-one counseling each year after the first year.

There is no copayment, coinsurance, or deductible for eligible patients receiving Medical Nutrition Therapy within the limitations listed.

Providers may prescribe additional hours of treatment if the patient’s condition changes; however, a claim may be denied if a provider recommends services for patients who do not meet the eligibility requirements, recommends services that Medicare does not cover, or requests services more often than Medicare covers.

Be sure to renew services yearly for patients if treatment continues into the next calendar year.

Claims processingTo avoid delays in processing claims and/or denials, it is imperative that your office staff do the following at every visit:

● Verify eligibility and benefits using the NaviNet® web portal prior to prescribing or rendering Medical Nutrition Therapy services.

● Obtain a copy of the member’s current ID card to ensure that you submit the most up-to-date information to AmeriHealth.

If you have any questions about coverage for Medical Nutrition Therapy services for Medicare Advantage HMO members, please contact your Network Coordinator or your Provider Partnership Associate.

NAVINET®


Changes coming in mid-September to NaviNet® The following new transactions and enhancements will be introduced on the NaviNet web portal in mid-September:

● Cash Management. This new transaction will provide a summary of payments applicable to members for the current six-month period (migrated member claims only). The designated NaviNet Security Officer within your office will initially receive access to this new transaction, and he or she will manage permissions for individual associates.

● Provider File Management. This new transaction replaces the previously retired Provider Change Form transaction. Provider File Management will allow professional providers to: - modify practice information - add hospital affiliations - add participating providers

● ICD-10. To support the October 1, 2015, compliance deadline for ICD-10, portal transactions that reference or leverage diagnosis codes will be updated. When submitting referrals, encounters, and authorization requests or when searching for a diagnosis on NaviNet for dates of service or dates of discharge (for facility inpatient claims) on or after October 1, 2015, providers must use ICD-10 codes.

● COB Questionnaire. A new transaction will be introduced with a new Coordination of Benefits (COB) Questionnaire. This electronic form will allow providers to report and submit Other Party Liability coverage for members. Reporting COB information at the time of service will help claims process correctly.

● Allowance Inquiry. New pricing mechanisms will be introduced to this transaction to help professional providers with rate searches.

More information about these new and updated transactions will be communicated in the coming weeks and through future editions of Partners in Health Update. In addition, we will also publish new user guides in the NaviNet Resources section of our Provider News Center at www.amerihealth.com/pnc/navinet to help you better navigate the listed transactions. Announcements will be made on AmeriHealth NaviNet Plan Central and on our Provider News Center once the new guides are available.

If you have any questions, please call the eBusiness Hotline at 215-640-7410 for AmeriHealth Pennsylvania and at 609-662-2565 for AmeriHealth New Jersey.

MEDICAL


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

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

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

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

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

Chiropractic services policy update On October 1, 2014, policy notifications for AmeriHealth Medicare Advantage HMO members were made available on the AmeriHealth Medical Policy Portal. The Medicare Advantage policies were developed in accordance with Centers for Medicare & Medicaid Services (CMS) coverage requirements and became effective on January 1, 2015. Chiropractic Services (#MA10.004) was one of the policies included in the Medicare Advantage book of policies.

Clarification to chiropractic services policyProvider feedback indicated that more clarity was required regarding the criteria in the chiropractic services policy. As a result, both the Policy and Coding and Billing Requirements sections of this policy have been updated to reflect that chiropractic services are covered when both the established coverage criteria and the medical necessity criteria are met in accordance with CMS guidelines.

To review Medical Policy #MA10.004a: Chiropractic Services, visit the Medical Policy Portal at www.amerihealth.com/medpolicy. Select Accept and Go to Medical Policy Online, select the Medicare Advantage tab from the top of the page, and then type the policy name or number in the Search field.

www.amerihealth.com/medpolicy

www.amerihealth.com/medpolicy

MEDICAL


Annual Synagis® (palivizumab) distribution program approaches The northeastern part of the United States is approaching the annual respiratory syncytial virus (RSV) season, which is November 2015 through March 2016. RSV is the most common cause of bronchiolitis and pneumonia among children younger than one year. During RSV season, AmeriHealth will approve the monthly administration of Synagis® (palivizumab) for children in accordance with the most recent recommendations from the American Academy of Pediatrics (AAP).

It is mandatory for all participating providers to obtain Synagis® (palivizumab) through ACRO Pharmaceutical Services.

If you have questions about the Synagis® (palivizumab) distribution program, please call Customer Service at 1-800-275-2583 for AmeriHealth Pennsylvania or 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey. The October 2015 edition of Partners in Health Update will include detailed information about how to order Synagis® (palivizumab), as well as the complete list of recommendations for Synagis® (palivizumab) from the AAP.

Learn moreReview Medical Policy #08.00.22l: Immune Prophylaxis for Respiratory Syncytial Virus (RSV) to learn more. Visit our Medical Policy Portal at www.amerihealth.com/medpolicy, select Accept and Go to Medical Policy Online, select the Commercial tab, and then type the policy name or number in the Search field.

Note: MedImmune, LLC, the maker of Synagis® (palivizumab), has a voluntary program called RSV ConnectionTM; however, AmeriHealth does not participate in this program.

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

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

● 17-alpha-hydroxyprogesterone caproate (17P), a preservative-free compound ● Makena® (hydroxyprogesterone caproate), which is approved by the U.S. Food and Drug Administration

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

For more information about 17P and Makena, review Medical Policy #08.01.00c: Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies. To do so, go to www.amerihealth.com/medpolicy, select Accept and Go to Medical Policy Online, select the Commercial tab, and then type the policy name or number in the Search field.

PHARMACY


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

Generic additionsThese generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the appropriate generic formulary level of cost-sharing:

Generic drug Brand drug Formulary chapter Effective date

adapalene lotion Differin® Lotion 5. Skin Medications April 6, 2015

cefixime susp 100 mg/5 ml and 200 mg/5 ml

Suprax® Susp 100 mg/5 ml and 200 mg/5 ml

1. Antibiotics & Other Drugs Used for Infection April 27, 2015

dexmethylphenidate hcl er 10 mg Focalin® XR 10 mg 3. Pain, Nervous System, & Psych February 9, 2015

doxycycline ir-dr Oracea® 1. Antibiotics & Other Drugs Used for Infection April 6, 2015

esomeprazole magnesium* Nexium® 8. Stomach, Ulcer, & Bowel Meds February 23, 2015

lamotrigine odt Lamictal® ODT 3. Pain, Nervous System, & Psych February 2, 2015

metaxalone 400 mg N/A 9. Bone, Joint, & Muscle April 6, 2015

methylphenidate hcl chewable tabs Methylin® Chewable Tabs 3. Pain, Nervous System, & Psych March 16, 2015

metoclopramide hcl Metozolv® ODT 8. Stomach, Ulcer, & Bowel Meds April 13, 2015

naproxen cr Naprelan® CR 9. Bone, Joint, & Muscle March 16, 2015

noreth-ethinyl estradiol/iron Generess® FE 10. Female, Hormone Replacement, & Birth Control April 6, 2015

pramipexole er 0.375 mg Mirapex® ER 0.375 mg 3. Pain, Nervous System, & Psych April 27, 2015

pramipexole er 0.75 mg and 1.5 mg

Mirapex® ER 0.75 mg and 1.5 mg 3. Pain, Nervous System, & Psych February 16, 2015

trandolapril-verapamil er Tarka® 4. Heart, Blood Pressure, & Cholesterol March 2, 2015

triamcinolone acetonide spray Kenalog® Spray 5. Skin Medications April 27, 2015

*Generic requires prior authorization.


PHARMACY


Brand deletionsEffective October 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Generic drug Formulary chapter

Generess® FE noreth-ethinyl estradiol/iron 10. Female, Hormone Replacement, & Birth Control

Mirapex® ER pramipexole er 3. Pain, Nervous System, & Psych

Oracea® doxycycline ir-dr 1. Antibiotics & Other Drugs Used for Infection

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

Effective October 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternative Formulary chapter

Alkeran® cyclophosphamide 2. Cancer & Organ Transplant Drugs

Epivir® HBV Sol adefovir, entecavir, lamivudine 1. Antibiotics & Other Drugs Used for Infection

Fareston® exemestane, letrozole, tamoxifen 2. Cancer & Organ Transplant Drugs

Hexalen® etoposide, letrozole, tamoxifen 2. Cancer & Organ Transplant Drugs

Kristalose® lactulose solution 8. Stomach, Ulcer, & Bowel Meds

Myleran® cyclophosphamide, Gleevec® 2. Cancer & Organ Transplant Drugs

Novoseven® RT Advate®, Feiba® NF, Hexilate® FS, Recombinate® 4. Heart, Blood Pressure, & Cholesterol

Rixubis® AlphaNine® SD, BeneFix®, Humate-P® 4. Heart, Blood Pressure, & Cholesterol

Viramune® XR 100 mg Atripla®, Complera®, nevirapine 200 mg, Sustiva® 1. Antibiotics & Other Drugs Used for Infection

Wilate® AlphaNine® SD, BeneFix®, Humate-P® 4. Heart, Blood Pressure, & Cholesterol

There are no generic equivalents for the above brand drugs; however, there are formulary therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate formulary level of cost-sharing. We encourage you to discuss formulary alternatives with your patients.


PHARMACY


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

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

Brand drug Generic drug Formulary chapter Effective date

Cholbam® Not available 8. Stomach, Ulcer, & Bowel Meds April 6, 2015

Corlanor® Not available 4. Heart, Blood Pressure, & Cholesterol April 27, 2015

CosentyxTM Not available 5. Skin Medications February 9, 2015

Cresemba® Not available 1. Antibiotics & Other Drugs Used for Infection March 30, 2015

EntrestoTM Not available 4. Heart, Blood Pressure, & Cholesterol July 13, 2015

EvekeoTM Not available 3. Pain, Nervous System, & Psych February 2, 2015

Farydak® Not available 2. Cancer & Organ Transplant Drugs March 9, 2015

Glyxambi® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones February 9, 2015

Ibrance® Not available 2. Cancer & Organ Transplant Drugs February 9, 2015

JadenuTM Not available 15. Diagnostics & Miscellaneous Agents April 13, 2015

Lenvima™ Not available 2. Cancer & Organ Transplant Drugs February 23, 2015

N/A fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg/hr patch 3. Pain, Nervous System, & Psych March 2, 2015

NatestoTM Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones March 16, 2015

Natpara® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones April 6, 2015

Novoeight® Not available 4. Heart, Blood Pressure, & Cholesterol March 16, 2015

Saxenda® Not available 3. Pain, Nervous System, & Psych April 13, 2015

Zubsolv® 8.6-2.1 mg Not available 3. Pain, Nervous System, & Psych February 9, 2015


PHARMACY


Effective October 1, 2015, the following non-formulary drugs will be added to the list of drugs requiring prior authorization:


Inderal® LA propranolol er 4. Heart, Blood Pressure, & Cholesterol

Oracea® doxycycline ir-dr 1. Antibiotics & Other Drugs Used for Infection

Pennsaid® 2% drops Not available 9. Bone, Joint, & Muscle

Tenoretic® atenolol/chlorthalidone 4. Heart, Blood Pressure, & Cholesterol

Tenormin® atenolol 4. Heart, Blood Pressure, & Cholesterol

Viibryd® Not available 3. Pain, Nervous System, & Psych

Wellbutrin® XL bupropion hcl xl 3. Pain, Nervous System, & Psych

Zorvolex® Not available 9. Bone, Joint, & Muscle

Effective October 1, 2015, the following drug category has been added to the list of drugs requiring prior authorization, and these requirements apply to all members:

Category

Compound products with total ingredient cost equal to or greater than $75 per prescription*

*All compounds will be covered at the appropriate non-formulary brand level of cost-sharing.

Drugs with quantity limitsQuantity limits were/will be added or updated for the following drugs as of the date indicated below:

Brand drug Generic drug Quantity limit Effective date

Aciphex® tabs rabeprazole tabs 60 tabs per 30 days October 1, 2015

Cresemba® Not available 68 caps per 30 days March 30, 2015

Dexilant® Not available 60 caps per 30 days October 1, 2015

Dilaudid® 1 mg/ml liquid hydromorphone 1 mg/ml liquid 360 ml per 30 days October 1, 2015

Entresto™ Not available 60 tabs per 30 days July 13, 2015

Evekeo™ 5 mg Not available 90 tabs per 30 days February 2, 2015

Evekeo™ 10 mg Not available 180 tabs per 30 days February 2, 2015

N/A fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg/hr patch 15 patches per 30 days March 2, 2015

Nexium® caps esomeprazole caps 60 caps per 30 days October 1, 2015

Prevacid® caps lansoprazole caps 60 caps per 30 days October 1, 2015



PHARMACY


Brand drug Generic drug Quantity limit Effective date

Prilosec® caps omeprazole caps 60 caps per 30 days October 1, 2015

Protonix® tabs pantoprazole tabs 60 tabs per 30 days October 1, 2015

Restasis® Not available 60 droperettes per 30 days October 1, 2015

Tussionex® ER susp hydrocodone/chlorpheniramine ER susp 120 ml per 30 days October 1, 2015

Zubsolv® 8.6-2.1 mg Not available 60 tabs per 30 days February 9, 2015

Drugs no longer requiring prior authorizationEffective July 1, 2015, the prior authorization requirement was removed for the following drugs:


Chantix® Not available 15. Diagnostics & Miscellaneous Agents

Toujeo Solostar® Not available 7. Diabetes, Thyroid, Steroids, & OtherMiscellaneous Hormones

various nicotine gum, lozenges, patches, and sprays 15. Diagnostics & Miscellaneous Agents

Zyban® bupropion 15. Diagnostics & Miscellaneous Agents

For additional information on pharmacy policies and programs, please visit www.amerihealth.com/rx for AmeriHealth Pennsylvania or www.amerihealthnj.com/html/providers/pharmacy for AmeriHealth New Jersey.


Let’s Go See initiative raises awareness of vision problems in childrenThis back-to-school season, Visionworks® and Davis Vision have teamed up to raise awareness of the importance of annual eye exams for children. This initiative, aptly named Let’s Go See, will not only serve as a public awareness campaign, but it will also help 10,000 children in need receive free eye exams and eyeglasses. AmeriHealth encourages physicians, especially pediatric physicians, to promote the Let’s Go See initiative.

Did you know that one in four children has a vision problem? According to Prevent Blindness America, 60 percent of children labeled as problem learners have an undetected vision problem. Many U.S. parents simply don’t know their children have a vision problem or don’t have the means to afford routine vision care. Let’s Go See commits to raising awareness of vision problems in children throughout the U.S. and the importance of an annual eye exam.

Please visit the Let’s Go See website at www.letsgosee.net for more information and to nominate a child, school, or organization in need of free comprehensive eye exams and eyeglasses.

Administered by Davis Vision. An affiliate of AmeriHealth has a financial interest in Visionworks.

HEALTH AND WELLNESS

HEALTH AND WELLNESS


Suicide: A concern for all health care providers

Part 3 – After screening/assessing: How to assure safety of the person who is at risk for suicideWhen it is determined that a patient is at risk for suicide, there could be many responses by the provider. One response that is becoming the standard for both behavioral health providers (BHP) and primary care physicians (PCP) is the Suicide Care Management Plan.1 The plan is developed in collaboration with the patient during an open discussion with the goal of preventing the patient from acting on his or her suicidal impulses. This response uses the healthy connectedness of the relationship between the provider and patient to promote coordination and collaboration that will assure safety for the patient. However, some patients are reluctant to tell providers that they may have suicidal ideas. For some, they are embarrassed, and for others, they may fear being hospitalized. In such cases, it is the responsibility of the provider to develop the trusting relationship that encourages all patients to talk openly about their concerns.2

For the PCP, an important aspect of the plan is to ensure that the patient is seen that same day by a BHP. If a BHP is not immediately available, contact Magellan Healthcare, Inc. by calling the phone number on the back of the member’s ID card and choosing the “Crisis” option to find providers. Another option is to refer the patient to a Crisis Center for a behavioral health evaluation. A list of local crisis centers will be available on www.amerihealth.com, www.amerihealthnj.com, and the NaviNet® web portal in the next few months.

For both the PCP and BHP, the Suicide Care Management Plan should also include the self-management techniques the patient will use to maintain his or her safety, which includes preventing access to means for suicide and how the patient will involve his or her support systems to enhance efforts to stay safe. Another important aspect of the plan includes follow-up with the patient to evaluate his or her status and make modifications, if necessary.3

Most importantly, all health care providers should do the following for a patient who is at risk for suicide: ● Discuss their concerns and Suicide Care Management Plan directly with the patient. ● Make sure the plan is brief and clear and that the patient has a copy. ● Encourage involvement of support systems. ● Always act for the safety of the patient.3

1www.zerosuicide.com2 Jobes, D, et al. Ethical and competent care of suicidal patients: Contemporary challenges, new developments, and considerations for clinical practice (2008). Professional Psychology: Research and Practice, Vol 39(4), Aug 2008, 405-413.

3 Stanley, B., & Brown, G. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. See more at http://zerosuicide.sprc.org/resources/safety-planning-intervention-brief-intervention-mitigate-suicide-risk#sthash.I6pNi6k5.dpuf.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most AmeriHealth members.

We are pleased to introduce the third in a short series of articles in Partners in Health Update, “Suicide: A concern for all health care providers,” that is designed to provide you with information on suicide and the importance of your role in assessing your patients who may be at risk.

http://zerosuicide.sprc.org/resources/safety-planning-intervention-brief-intervention-mitigate-suicide-isk%20-%20sthash.I6pNi6k5.dpuf

http://zerosuicide.sprc.org/resources/safety-planning-intervention-brief-intervention-mitigate-suicide-isk%20-%20sthash.I6pNi6k5.dpuf

www.zerosuicide.com

*The Provider Automated System is available only for those members who have not yet been migrated to our new operating platform. Go to www.amerihealth.com/pnc/changes for more information.

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

Important ResourcesAnti-Fraud and Corporate Compliance

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

Care Management and Coordination

Baby FootSteps® 1-800-313-8628, prompt 3 (NJ only) 1-800-598-BABY (2229) (PA only)

Case Management 1-800-313-8628

ConnectionsSM Health Management Program (for commercial NJ members only) 1-888-YOUR-AH1 (968-7241) N/A

Condition Management (for commercial PA members and Medicare Advantage NJ members) N/A 1-800-313-8628

Credentialing

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

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

Customer Service/Provider ServicesProvider Automated System* (eligibility/claims status/precertification) 1-888-YOUR-AH1 (968-7241) (NJ only) 1-800-275-2583 (PA only)

Provider Services user guide www.amerihealth.com/providerautomatedsystem

Electronic Data Interchange (EDI)

Highmark EDI Operations 1-800-992-0246

FutureScripts® (commercial pharmacy benefits)

Pharmacy benefits 1-888-678-7012

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

FutureScripts® Secure (Medicare Part D pharmacy benefits)

FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.amerihealthmedicare.com

Imaging services

CT, MRI/MRA, PET, and nuclear cardiology 1-800-859-5288 (NJ only) 1-800-275-2583 (PA only)

NaviNet® web portal

AmeriHealth eBusiness Hotline 609-662-2565 (NJ only) 215-640-7410 (PA only)

Registration www.navinet.net

Other frequently used websites and phone numbers

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

Medical Policy www.amerihealth.com/medpolicy

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

sm september 2015 · 2019-10-11 · procedure coding system (hcpcs) codes will continue to be used...

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