SM February 2015ICD-10: External testing with providers to resume in early 2015 As a reminder, the...

updateSM

New changes to our ePASS® incentive opportunity for professional providers page 7

ICD-10: External testing with providers to resume in early 2015 page 4

Additional HIPPS code requirements for certain SNF claims/encounters page 5

February 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 2013 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]

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 Commendable from the NCQA.

► 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

Inside this edition Administrative

● Stay informed during our transition to a new platform ............3 ► Updated time frame for processing PCP changes .................3

ICD-10 ► ICD-10: External testing with providers to resume in early 2015 ..............................................................................4

NaviNet®

► NaviNet changes delayed until March ....................................4

Billing ► Additional HIPPS code requirements for certain SNF claims/encounters ..................................................................5

Medical ► Precertification and compliance monitoring for PAP machines and supplies ..........................................................................6 ► Medical and claim payment policy activity posted from December 20, 2014 – January 23, 2015 ...............................7 ► New changes to our ePASS® incentive opportunity for professional providers ...........................................................7

Credentialing ● Reminder: Changes to the CAQH recredentialing process ....8

Quality Management ● Highlighting HEDIS®: Pharmacotherapy management of COPD exacerbation ...........................................................................9

Health and Wellness ● Encourage pregnant AmeriHealth members to register for Baby FootSteps® ..............................................................................10

● Help your Medicare Advantage patients get fit in 2015 ..........11

www.dreamstime.com

mailto:[email protected]

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

Stay informed during our transition to a new platformAs you may know, AmeriHealth is in the process of transitioning its membership to a new operating platform. Our migration of AmeriHealth Pennsylvania commercial members is nearly complete, and all AmeriHealth New Jersey Medicare Advantage HMO members were migrated to the new platform on January 1, 2015. Additionally, AmeriHealth New Jersey commercial members will be migrated to the new platform by October 1, 2015.

During this transition, we are working with you in a dual claims-processing environment. In other words, we are processing a larger portion of claims and business transactions on the new platform as members are migrated, and we continue to process claims and conduct business transactions on the current platform for members who have not yet been migrated.* The date of service will determine the platform on which claims are processed.

We are committed to working closely with our entire provider network as we complete this transition. We will continue to provide comprehensive communications and resources to support our members and provider network, both during and after the transition to the new platform.

Be sure to visit our dedicated System and Process Changes site at www.amerihealth.com/pnc/changes. On this site you will find several resources, including a communication archive and frequently asked questions. If you still have questions after reviewing these resources, email us at [email protected].

*Behavioral health claims for HMO/POS non-migrated members should continue to be submitted to Magellan Behavioral Health, Inc. Behavioral health claims for all migrated members, including HMO/POS, should be submitted to AmeriHealth.

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

Updated time frame for processing PCP changesTo provide consistency for all members, effective February 6, 2015, AmeriHealth will update the processing time frame and criteria when members choose a new primary care physician (PCP).

Beginning in February, the PCP change process for all commercial and Medicare Advantage members will be as follows:

● When members request a PCP change, they will need to provide a reason for the change. The change will take effect 14 calendar days later or the 1st of the following month, whichever comes first.

● Note: The two exceptions to this timing are if 1) the change is due to No Initial PCP Selection or 2) Current PCP no Longer in Network, in which case the change takes effect the 1st of the current month.

Members can change their PCP through our secure member website, www.amerihealthexpress.com, by using the AHNJ On the Go app (for AmeriHealth New Jersey members only), or by calling Customer Service. Providers cannot make a change to a member’s PCP on the member’s behalf.

ADMINISTRATIVE


ICD-10: External testing with providers to resume in early 2015 As a reminder, the U.S. Department of Health and Human Services has confirmed in a final rule that October 1, 2015, will be the compliance deadline for the implementation of ICD-10. The final rule requires the continued use of ICD-9 through September 30, 2015.

External testingAmeriHealth is currently in the process of reassessing and communicating our external testing plan and schedule. In the coming months, we will resume testing with our pre-established testing partners and share our successes and challenges with our provider network.

Learn moreDetailed information about ICD-10 and the road to compliance will continue to be communicated in future editions of Partners in Health Update and within the ICD-10 section of our website at www.amerihealth.com/icd10.

ICD-10

NaviNet changes delayed until MarchIn the January edition of Partners in Health Update, we communicated the following significant upcoming changes to the NaviNet web portal:

● NaviNet office conversion ● new Allowance Inquiry transaction ● new Network Provider Inquiry/Network Facility Inquiry transactions ● tiering information enhancements

Please be aware that these changes have been delayed until March. Look for more information in the next edition of Partners in Health Update.

For more information about changes to NaviNet, we strongly encourage you to review the NaviNet Transaction Changes section of our System and Process Changes site at www.amerihealth.com/pnc/changes. 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.

NAVINET®


Additional HIPPS code requirements for certain SNF claims/encounters As previously communicated, the Centers for Medicare & Medicaid Services (CMS) require that all Medicare Advantage Organizations (MAO) submit Health Insurance Prospective Payment System (HIPPS) codes on all Skilled Nursing Facility (SNF) and Home Health Agency (HHA) claims/encounters with a “from” date on or after July 1, 2014. The original communication from CMS indicated that the HIPPS codes should come from the initial Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessment (Admission assessment) and Outcome and Assessment Information Set (Start of Care assessment), respectively.

SNF claims/encountersRecently, AmeriHealth received further guidance from CMS regarding this requirement for SNF encounters when no Admission assessment was completed during the Medicare Advantage (MA)-covered stay. The requirements previously communicated, as well as this new guidance from CMS, extend through 2015 dates of service. The following rules apply if there was no Admission assessment completed during the MA-covered part of the stay:

● Stays of more than 14 days. If the Admission assessment for a stay in the facility was completed prior to the MA-covered portion of the stay, MAOs must submit to CMS a HIPPS code by following the guidance in the order they are listed below:

— Submit the HIPPS code from another assessment completed during the MA-covered portion of the stay. If the OBRA Admission assessment was completed for the current stay prior to the MA-covered portion of the stay, and another assessment (e.g., Quarterly Assessment or any Prospective Payment System assessment required by the MAO) was completed during the MA-covered portion of the stay, the MAO shall submit the HIPPS code generated from that other assessment on their encounter submissions to CMS.1

— Submit the HIPPS code from the most recent assessment that was completed prior to the MA-covered portion of the stay. If no assessment was completed during the MA-covered portion of the stay from which a HIPPS code could be generated, the MAO shall submit to CMS the HIPPS code from the most recent OBRA or other assessment that was completed prior to the MA-covered portion of the stay (which may be the Admission assessment).1

● Stays of 14 days or less. If there was no Admission assessment completed before discharge for a stay of less than 14 days, MAOs must submit to CMS a HIPPS code by following the guidance in the order they are listed below:

— Submit the HIPPS code from another assessment from the stay. If no OBRA Admission assessment was completed for a SNF stay of less than 14 days, the MAO shall submit to CMS the HIPPS code from any other assessment that was completed during the stay that produces a HIPPS code.1

— Submit a default HIPPS code of “AAA00.” MAOs may submit a default HIPPS code for SNF encounter submissions to CMS only if: 1) the SNF stay was less than 14 days within a spell of illness, 2) the beneficiary has been discharged prior to the completion of the initial OBRA Admission assessment, and 3) no other assessment was completed during the stay.2 To submit a default HIPPS code to the Encounter Data System, MAOs should use the default Resource Utilization Group code of “AAA” and Assessment Indicator “00” on encounter data submissions starting with “from” dates of service July 1, 2014. MAOs may not use this default code in other situations, such as to avoid collecting the proper HIPPS code, or when the MAO’s systems are not prepared to submit the HIPPS code to CMS.

As a reminder, all SNF and HHA claims/encounters must be submitted on the 837-Institutional format.

If you have any questions about these requirements, please contact your Hospital/Ancillary Services Coordinator.

1 CMS understands that some MAOs require providers to conduct assessments similar to those used under traditional Medicare Part A Prospective Payment System (PPS) rules. Providers may submit to MAOs, and MAOs can submit to the Encounter Data System, HIPPS codes derived from the same item set and data specifications as those used under the SNF PPS. We note that, in such cases, providers must not submit these assessments through the traditional PPS assessment system.

2 Per the Assessment Management Requirements and Tips for Comprehensive Assessments (RAI Manual, pg. 2-17): “If a resident is discharged prior to the completion deadline for the assessment, completion of the assessment is not required.” Federal statute and regulations require that SNFs and Nursing Facilities promptly assess residents upon admission but no later than the 14th calendar day of the resident’s admission (admission date + 13 calendar days).

BILLING


Precertification and compliance monitoring for PAP machines and supplies In an effort to help our members receive appropriate, safe, and affordable care for obstructive sleep apnea (OSA) and other sleep disorders, AmeriHealth has partnered with AIM Specialty Health® (AIM). The goal is to streamline the precertification process for sleep studies, APAP, BPAP, and CPAP (PAP) machines and supplies (e.g., tubing, water chambers, masks) and enhance member compliance with prescribed usage.

Precertification requirementsAs of January 1, 2015, in addition to obtaining precertification for PAP machines, durable medical equipment (DME) providers are also required to obtain precertification for all related supplies. This requirement applies to all new and existing patients on PAP therapy.

Currently, ordering providers request precertification of sleep studies and CPAP titration studies in the facility setting through AIM. Beginning on February 16 2015, DME providers will be required to submit precertification requests for PAP machines and all related supplies (e.g., tubing, water chambers, masks) through AIM.

We are making enhancements to the NaviNet® web portal to accommodate the submission of precertification requests through the AIM Provider PortalSM using the AIM transaction. Once implemented, providers must obtain precertification through AIM.

Note: Until the enhancements are completed, providers should continue to submit precertification requests for PAP machines and supplies using the Authorizations transaction in NaviNet. We will post a notification on NaviNet Plan Central once the AIM Provider PortalSM is updated.

Compliance monitoring requirementsTo ensure that our members are using their PAP machines as prescribed by the ordering provider, AIM incorporates a compliance element to their precertification process, which will begin on February 16, 2015. Usage data will be collected for all members using PAP therapy. This data will be analyzed by AIM to determine if the member has been compliant in using their PAP machine and if a request for precertification of continued rental and/or supplies will be approved or denied.

For members who are new to PAP therapy, DME providers must contact AIM to request approval for the initial PAP set-up, prior to dispensing equipment and

supplies. For those members currently on PAP therapy, the DME provider must also contact AIM to request approval for on-going treatment. DME providers will need to submit the date upon which the member initiated PAP therapy on the current device – regardless of payer. The AIM system will then calculate where the member is in the rental cycle, if applicable.

Please note the following when requesting precertification through AIM:

● Rentals. During the rental period, the precertification will cover the PAP machine, humidifier, and all supplies. The precertification will be good for up to 90 days.

● Owned. Once the rental period ends, the precertification will cover only supplies (A-codes). The precertification will be good for one year.

If AIM denies a precertification request after analyzing the compliance data, a denial letter will be mailed to the DME provider, the ordering provider, and the member. This notification encourages the ordering provider to contact the member and determine the appropriate next steps.

GuidelinesAmeriHealth will adopt and follow AIM’s Clinical Guidelines, which are available on AIM’s website at www.aimspecialtyhealth.com, when reviewing precertification requests for our commercial members. AIM will follow the established Medicare coverage guidance when reviewing requests for our Medicare Advantage HMO members. Policy Notifications for the following policies, which address sleep disorder testing, are available at www.amerihealth.com/medpolicy. Included within the policies are links to the guidelines that AIM will use to determine usage compliance and medical necessity for PAP machines and supplies, a complete list of codes that require precertification, and quantity limits set for the supplies.

● Commercial: #07.03.05r: Sleep Disorder Testing and Positive Airway Pressure Therapy

● Medicare Advantage: #MA07.058a: Sleep Disorder Testing and Positive Airway Pressure Therapy

If you have any questions about this new precertification requirement, please call Customer Service at 1-800-275-2583 for AmeriHealth Pennsylvania and at 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey.

MEDICAL


New changes to our ePASS® incentive opportunity for professional providers As previously announced, changes were made to the incentive opportunity for primary care providers who have face-to-face encounters and submit SOAP (Subjective, Objective, Assessment, and Plan) Progress Notes for their members. These included limitations to the incentive payment.

Based on a two-year analysis, we are making additional changes to the requirements for submitting a SOAP (Subjective, Objective, Assessment, and Plan) Progress Note through ePASS® for Medicare Advantage HMO members, as well as certain commercial HMO, POS, and PPO members.

During the analysis, it was found that 98 percent of relevant medical information was collected in two SOAP Progress Notes submissions per year. Also, there was little evidence to show that care gaps were closed when visits occurred within a short time frame.

Effective January 1, 2015, AmeriHealth New Jersey implemented the following changes: ● Providers can submit two SOAP Progress Notes per member, per calendar year. Previously they could only submit one SOAP Progress Note per member, per calendar year.

● The submission for the second visit will be valid only if the visit occurred no more than four months after the first visit for which you submitted the initial SOAP Progress Note.

If you have any questions regarding submitting SOAP Progress Notes or using ePASS®, please contact Inovalon at 1-877-448-8125. For questions about this initiative, please contact Customer Service at 1-888-YOUR-AH1 (1-888-968-7241).

Medical and claim payment policy activity posted from December 20, 2014 – January 23, 2015 Each month, new policy activity is posted to our Medical Policy Portal. Policy activity may include new, updated, reissued, or archived policies and coding updates.

Included with this edition of Partners in Health Update is a supplementary listing of policy activity that occurred for our commercial and Medicare Advantage portfolios from December 20, 2014 – January 23, 2015.

For the most up-to-date information about medical and claim payment policy activity, go to www.amerihealth.com/medpolicy and select Accept and Go to Medical Policy Online. Then select either the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you’d like to view. You can also get to our Medical Policy Portal through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

MEDICAL

www.amerihealth.com/medpolicy


Reminder: Changes to the CAQH recredentialing process*AmeriHealth offers our participating providers the Council for Affordable Quality Healthcare® (CAQH) Universal Provider DataSource® (UPD) for completing the recredentialing process. The CAQH UPD is a single, national process that eliminates the need for completing multiple recredentialing applications.

Beginning in February 2015, CAQH is making significant improvements to simplify the recredentialing process even further. Along with these improvements comes a new name: CAQH ProViewTM.

Benefits of using CAQH ProViewThe following new features will make it easier for health care providers to make updates — reducing the time and resources necessary to submit accurate, timely data to AmeriHealth:

● complete and attest to multiple state credentialing applications in one intelligent workflow design; ● upload supporting documents directly into CAQH ProView to eliminate the need for manual submission and to improve the timeliness of completed applications;

● review and approve Practice Manager information before data is imported; ● protect against delays in data processing with more focused prompts and real-time validation; ● self-register with the system before a health plan initiates the application process.

New submission process When CAQH ProView launches in February 2015, all providers must apply online. Paper applications will no longer be accepted. CAQH ProView is a completely electronic solution, allowing providers to easily submit information through a more intuitive, profile-based design. The CAQH electronic credentialing application is free to providers and available on the CAQH website at https://upd.caqh.org/oas. AmeriHealth may still request paper documentation, such as billing forms and contracts; however, the initial credentialing and recredentialing process with CAQH will be paperless.

Note: Providers in New Jersey can also use the New Jersey Universal Physician Application form.

If you have questions about CAQH ProView, please email them to [email protected].

*This does not apply to Magellan Behavioral Health contracted providers.

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

CREDENTIALING


Highlighting HEDIS®: Pharmacotherapy management of COPD exacerbation

HEDIS® definitionPharmacotherapy management of COPD exacerbation: The percentage of chronic obstructive pulmonary disease (COPD) exacerbations for members ages 40 and older who had an acute inpatient discharge or emergency department visit on or between January 1 – November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported:1. Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event;2. Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event.

Note: The eligible population for this measure is based on acute inpatient discharges and emergency department visits, not on members. It is possible for the denominator to include multiple events for the same individual.

Plan performanceFor this measure, the HEDIS 2014 rates‡ for all AmeriHealth New Jersey plans fall below the HEDIS 90th percentile benchmark, an industry indicator of excellence and desired target for each plan. Performance compared to the HEDIS 90th percentile is broken down by line of business and plan type below.

Why this measure is importantWhile other major causes of death have been decreasing, COPD mortality has risen, making it the fourth leading cause of death in the U.S. The disease results in both direct and indirect costs, and exacerbations of COPD account for the greatest burden on the health care system, though studies have shown that proper management of exacerbations may have the greatest potential to reduce the clinical, social, and economic impact of the disease. Pharmacotherapy is an essential component of proper management.

— NCQA, HEDIS 2015 V1

Did you know?AmeriHealth New Jersey case managers can collaborate with you to support and guide patients through an acute or chronic episode to help achieve the medical treatment goals you establish.

Please provide the AmeriHealth New Jersey case management line phone number to your patients. AmeriHealth New Jersey case managers can support your patients as they make important decisions about their health. Ask them to call 1-800-YOUR AH1 (1-800-968-7241) and say “Case Management” when prompted.

*The National Committee for Quality Assurance (NCQA) is the most widely recognized accreditation program in the U.S.† The Healthcare Effectiveness Data and Information Set (HEDIS) is an NCQA tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care.

‡HEDIS 2014 rates reflect data collected in 2013.

Systemic corticosteroid dispense rateSource Commercial Medicare

HMO PPO HMOAmeriHealth New Jersey 66.7% N/A N/AHEDIS 90th percentile 81.0% 78.0%

QUALITY MANAGEMENT

This article series is a monthly tool to help physicians maximize patient health outcomes in accordance with NCQA’s* HEDIS®† measurements for high quality care on important dimensions of services. If you have feedback or would like to request a topic, email us at [email protected].

Bronchodilator dispense rateSource Commercial Medicare

HMO PPO HMOAmeriHealth New Jersey 69.4% N/A N/AHEDIS 90th percentile 88.0% 89.0%


Encourage pregnant AmeriHealth members to register for Baby FootSteps®

The Baby FootSteps program supports expectant mothers and promotes a healthy pregnancy throughout each trimester. We ask that you inform pregnant AmeriHealth members about the Baby FootSteps program at their first prenatal visit and encourage them to self-enroll as outlined below:

● AmeriHealth Pennsylvania members: Please encourage these members to self-enroll by calling our toll-free number, 1-800-598-BABY. Upon calling, a Health Coach will explain the program to the member and ask her a series of questions to complete the enrollment process.

● AmeriHealth New Jersey members: Please encourage these members to self-enroll by calling 1-800-313-8628, selecting prompt 3, and leaving a message. Members can also log on to our secure member website, amerihealthexpress.com, to complete an online form to contact a case manager.

Once enrolled in the program, Pennsylvania members will receive a welcome letter that includes information on how to access educational materials on our secure member website, amerihealthexpress.com, and the 1-800-598-BABY phone number for questions and support during pregnancy. In addition, high-risk members will be given the name and contact information for their Health Coach. New Jersey members will continue to receive the same information they do today.

Resources availableA flyer is available upon request to place in the member’s chart and distribute at the first prenatal visit to encourage her to enroll in Baby FootSteps. To order flyers, please submit an online request at www.amerihealth.com/providersupplyline or call the Provider Supply Line at 1-800-858-4728.

If you have any questions, 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.

Postpartum office visits As a reminder, postpartum visits should be scheduled 21 to 56 days after delivery. Adhering to this time frame provides the best opportunity to assess the physical healing for new mothers and to prescribe contraception, if necessary. These visits should be scheduled before members are discharged from the hospital.

HEALTH AND WELLNESS


Help your Medicare Advantage patients get fit in 2015You likely have patients who have made resolutions about their health for 2015. The most common resolutions are to lose weight, get in shape, and be healthier. However, these are also some of the most difficult goals to attain. Luckily, your AmeriHealth New Jersey Medicare Advantage patients have a great resource to help them keep their resolutions: Healthways SilverSneakers® Fitness program (SilverSneakers).

SilverSneakers program detailsSilverSneakers is one of the nation’s leading fitness programs designed exclusively for older adults and is available at no additional cost for our AmeriHealth 65® NJ HMO and AmeriHealth 65® Preferred HMO members. The program offers several options for members at any fitness level, from those just starting an exercise regimen to accomplished athletes. SilverSneakers members can choose one option or use them all. The program includes:

● A fitness membership. SilverSneakers members have access to more than 12,000 fitness locations across the country, the membership includes: all basic amenities plus SilverSneakers group fitness classes, fun social activities, and a Program Advisor™ for guidance and assistance. Members can use any SilverSneakers location any time they are open; there are no access restrictions. Members only need to present their SilverSneakers ID number at any participating fitness location to use all basic amenities and participate in SilverSneakers classes.

● SilverSneakers FLEX™. FLEX offers classes and activities such as tai chi, dance, yoga, walking and hiking groups at parks, recreation centers and other neighborhood locations. FLEX participants can attend their favorite SilverSneakers fitness location concurrently.

● Online support. The SilverSneakers member website provides tools for members to assess their health, track their activity, access expert fitness advice, download meal plans and healthy recipes, and receive support from the SilverSneakers community.

● SilverSneakers Steps®. Members who cannot get to a SilverSneakers fitness location can order a SilverSneakers Steps kit – general fitness, strength, walking, or yoga – to use at home. As with other SilverSneakers features, there is no extra cost to the member for a Steps kit.

Getting started with SilverSneakers is simple. Members only need to take their SilverSneakers ID number to their closest location to tour the facility, sign up, and start working out. For more information on the program or to help your patients find their closest SilverSneakers location or get their ID number, visit silversneakers.com or call 1-888-423-4632 (TTY: 711) Monday through Friday, 8 a.m. - 8 p.m. local time.

No matter which SilverSneakers options your AmeriHealth 65® Medicare Advantage patients choose, they can keep their resolutions this year! Encourage your patients to start using their SilverSneakers membership now for a healthier 2015.

SilverSneakers is a registered mark of Healthways, Inc.

HEALTH AND WELLNESS

www.silversneakers.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

AmeriHeatlh 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 Injectables Program (medical benefits) www.amerihealth.com/directship

Medical Policy www.amerihealth.com/medpolicy

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

www.amerihealth.com/antifraud

www.amerihealth.com/credentials

www.amerihealth.com/providerautomatedsystem

www.amerihealth.com/rx

www.amerihealthmedicare.com

www.navinet.net

www.amerihealth.com/directship

www.amerihealth.com/medpolicy

www.amerihealth.com/providersupplyline

www.amerihealth.com/pnc

December 20, 2014 – January 23, 2015 1

Medical and claim payment policy activity Commercial business

The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from December 20, 2014 – January 23, 2015.

For the most up-to-date information about medical and claim payment policy activity for commercial business, go to www.amerihealth.com/medpolicy, select Accept and Go to Medical Policy Online, and then select the Commercial tab. You can also view policy activity using the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

New policiesThe following commercial policies have been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with AmeriHealth.

Policy # Title Notifi cation date Effective date

00.01.59 Care Management and Coordination Services 12/1/2014 1/1/2015(published 12/31/2014)

00.01.60 Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services 10/1/2014 1/1/2015

(published 12/31/2014)

05.00.74 Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies 12/1/2014 1/1/2015


06.02.44 Presumptive and Defi nitive Drug Testing 12/1/2014 1/1/2015(published 12/31/2014)

07.05.08 Fecal Microbiota Transplantation (FMT) 12/12/2014 1/1/2015(published 12/31/2014)

08.01.19 Siltuximab (Sylvant™) N/A 1/15/2015

08.01.20 Programmed Cell Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®) N/A 1/15/2015

09.00.56 Radiation Therapy Services (AmeriHealth Pennsylvania) 12/12/2014 1/1/2015(published 12/31/2014)

Updated policies The following commercial policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other procedures for doing business with AmeriHealth.

Policy # Title Type of policy change Notifi cation date Effective date

00.01.47b Inpatient Hospital Readmission

General Description, Guidelines, or Informational Update; Coverage and/or Reimbursement Position

12/1/2014 1/1/2015(published 12/31/2014)

00.01.56aNational Correct Coding Initiative (NCCI) Code Pair Edits

Coverage and/or Reimbursement Position 10/1/2014 1/1/2015


05.00.05hEquipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes

Medical Necessity Criteria 1/5/2015 2/9/2015

07.02.03h Implantable Cardiac Loop Monitor

Coverage and/or Reimbursement Position; Medical Coding; General Description, Guidelines, or Informational Update

10/3/2014 1/1/2015(published 12/31/2014)



07.03.05rSleep Disorder Testing and Positive Airway Pressure Therapy

Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

1/15/2015 2/15/2015

08.00.76e Oxaliplatin (Eloxatin®)Medical Necessity Criteria; General Description, Guidelines, or Informational Update

N/A 1/15/2015

08.00.84b Eculizumab (Soliris®) General Description, Guidelines, or Informational Update N/A 1/15/2015

08.00.97e

Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)


N/A 1/15/2015

08.01.02b Pegloticase (Krystexxa®) General Description, Guidelines, or Informational Update N/A 1/15/2015

09.00.48dRadioembolization for Primary and Metastatic Tumors of the Liver

General Description, Guidelines, or Informational Update N/A 1/1/2015


09.00.49g Proton Beam Radiation Therapy

Coverage and/or Reimbursement Position; Medical Necessity Criteria 12/31/2014 3/31/2015

11.00.16eRadiofrequency Ablation and Cryosurgical Ablation of Lung Tumors

Coverage and/or Reimbursement Position; Medical Necessity Criteria 10/3/2014 1/1/2015


11.05.17a

Implantable Miniature Telescope™ (IMT) for the Treatment of End-Stage, Age-Related Macular Degeneration (AMD)

Medical Necessity Criteria N/A 1/15/2015

11.15.23c

Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management

Coverage and/or Reimbursement Position; Medical Necessity Criteria; Medical Coding

10/3/2014 1/1/2015(published 12/31/2014)

12.00.03c Alternative Therapies and Complementary Medicine Medical Necessity Criteria N/A 1/14/2015

12.01.01aa Experimental/Investigational Services

Medical Coding; Medical Necessity Criteria N/A 1/1/2015


Reissued policiesThe following commercial policies have been reviewed, and no substantive changes were made.

Policy # Title Reissue effective date

Reissue published date

00.01.44e Never Events and Preventable Adverse Events 1/6/2015 1/9/2015

01.00.03b Organ and Tissue Recovery from a Cadaveric Donor and Associated Services 1/6/2015 1/9/2015

02.01.02b Private Duty Nursing 1/6/2015 1/9/2015

02.02.01f Hospice and Respite Care 1/6/2015 1/9/2015

05.00.08d Continuous Passive Motion (CPM) Devices in the Home Setting 1/7/2015 1/9/2015

05.00.14g High-Frequency Chest Wall Oscillation Devices 1/7/2015 1/9/2015

05.00.25f Cranial Remolding Orthoses (Helmets) 1/21/2015 1/21/2015

05.00.29h Automatic External and Wearable Cardioverter Defi brillators 1/21/2015 1/23/2015

05.00.61e Cervical Traction for In-home Use 1/7/2015 1/9/2015

05.00.65d Home Uterine Activity Monitoring (HUAM) Devices 1/6/2015 1/9/2015




05.00.71b Standing Frames 1/21/2015 1/22/2015

05.00.72c Upper Limb Prostheses 1/21/2015 1/23/2015

07.08.01e Non-Surgical Spinal Decompression Therapy 1/6/2015 1/9/2015

07.10.04b Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor 1/6/2015 1/9/2015

07.10.05e Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System 1/6/2015 1/9/2015

07.12.01d Pelvic Floor Stimulation as a Treatment of Incontinence 1/21/2015 1/22/2015

07.13.11e Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects 1/21/2015 1/22/2015

07.13.14a The Argus® II Retinal Prosthesis 1/21/2015 1/22/2015

08.00.64e Natalizumab (Tysabri®) 1/21/2015 1/22/2015

08.01.13 Brentuximab Vedotin (Adcetris®) 1/21/2015 1/22/2015

11.01.07b Cataract Surgery 1/21/2015 1/22/2015

11.04.01c Islet Cell Transplantation 1/7/2015 1/9/2015

11.06.02f Elective Abortion 1/6/2015 1/9/2015

11.08.01e Hair Transplants and Cranial Prostheses (Wigs) 1/21/2015 1/22/2015

Coding updatesThe following commercial policies have been reviewed and updated to add new and revised medical codes (e.g., ICD-9 and ICD-10 diagnosis codes; CPT® and HCPCS codes; revenue codes) and/or remove terminated medical codes.

Policy # Title Effective date Published date00.01.24f Obsolete or Unreliable Diagnostic Tests and Medical Services 1/1/2015 1/2/2015

00.06.02m Preventive Care Services 1/1/2015 12/31/2014

00.10.15b Cast and Splint Applications and Associated Supplies Provided in the Offi ce Setting 1/1/2015 1/23/2015

00.10.20l Add-on Codes 1/2/2015 1/23/2015

03.00.06lModifi er 25: Signifi cant, Separately Identifi able Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service

1/1/2015 1/23/2015

03.00.15l Modifi er 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period 1/1/2015 1/23/2015

03.00.29i Modifi er 51 Exempt 1/1/2015 1/23/2015

03.02.13e Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG) 1/1/2015 1/23/2015

05.00.05g Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes 1/1/2015 12/31/2014

05.00.21n Durable Medical Equipment (DME) 1/1/2015 12/31/2014

05.00.38i Negative-Pressure Wound Therapy (NPWT) Systems 1/1/2015 12/31/2014

05.00.44g Repair and Replacement of Durable Medical Equipment (DME) 1/1/2015 12/31/2014

05.00.45h Repair or Replacement of an External Prosthetic Device 1/1/2015 12/31/2014


Policy # Title Effective date Published date

05.00.54g Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices 1/1/2015 12/31/2014

05.00.59h Lower Limb Prostheses 1/1/2015 12/31/2014

05.00.61e Cervical Traction for In-home Use 1/1/2015 1/7/2015

05.00.72c Upper Limb Prostheses 1/1/2015 12/31/2014

06.02.10mGenetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome)

1/1/2015 12/31/2014

06.02.18h Pharmacogenetics and Metabolite Monitoring Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy 1/1/2015 12/31/2014

06.02.24g Preimplantation Genetic Testing 1/1/2015 12/31/2014

06.02.27f Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis 1/1/2015 12/31/2014

06.02.35h Genetic Testing 1/1/2015 12/31/2014

06.02.38a Nerve Fiber Density Testing 1/1/2015 12/31/2014

07.00.03m Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy 1/1/2015 12/31/2014

07.03.07l Evaluation and Management of Autism Spectrum Disorders (ASD) 1/1/2015 12/31/2014

07.06.03b Bioimpedance for the Detection of Lymphedema 1/1/2015 12/31/2014

07.08.03b Medical and Surgical Treatment of Temporomandibular Joint Disorder 1/1/2015 12/31/2014

07.10.05e Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System 1/1/2015 12/31/2014

07.10.06b Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation 1/1/2015 12/31/2014

08.00.57h Complex Regional Pain Syndrome (CRPS) Parenteral Treatments 1/1/2015 12/31/2014

08.00.75i Erythropoiesis-Stimulating Agents (ESAs) 1/1/2015 12/31/2014

08.00.78o Self-Administered Drugs 1/1/2015 12/31/2014

08.00.92k Coagulation Factors for Hemophilia 1/1/2015 12/31/2014

08.01.04i Preventive Immunization 1/1/2015 12/31/2014

08.01.14a Radium Ra 223 dichloride (Xofi go®) Injection 1/1/2015 12/31/2014

08.01.17a Elosulfase alfa (Vimizim™) 1/1/2015 12/31/2014

09.00.10r Brachytherapy 1/1/2015 12/31/2014

09.00.17k Intensity Modulated Radiation Therapy (IMRT) 1/1/2015 12/31/2014

09.00.40c Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA) 1/1/2015 12/31/2014

09.00.46n High-Technology Radiology Services 1/1/2015 12/31/2014

09.00.49f Proton Beam Radiation Therapy 1/1/2015 12/31/2014

09.00.52b Digital Breast Tomosynthesis 1/1/2015 12/31/2014

11.02.12fPercutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery

1/1/2015 12/31/2014

11.03.02o Bariatric Surgery 1/1/2015 12/31/2014


Continue to the next page for information about Medicare Advantage policy activity.

Policy # Title Effective date Published date11.03.12k Colorectal Cancer Screening 1/1/2015 12/31/2014

11.05.16b Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma 1/1/2015 12/31/2014

11.08.15s Reconstructive Breast Surgery 1/1/2015 12/31/2014

11.08.23h Mohs' Micrographic Surgery 1/1/2015 12/31/2014

11.08.25k Scar Revision 1/1/2015 12/31/2014

11.11.06f Saturation Needle Biopsy of the Prostate 1/1/2015 12/31/2014

11.14.07l Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis 1/2/2015 12/31/2014

11.14.10l Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty 1/1/2015 12/31/2014

11.14.19h Artifi cial Intervertebral Disc Insertion 1/1/2015 12/31/2014

11.15.01m Spinal Cord Stimulation (Dorsal Column Stimulation) 1/1/2015 12/31/2014

11.17.04n Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence 1/1/2015 12/31/2014

Archived policiesThe following are commercial policies that AmeriHealth has determined are no longer necessary to remain active.

Policy # Title Notifi cation date Archive effective date

08.00.06g Inpatient Administration of Intravenous Dihydroergotamine Mesylate (D.H.E. 45®) 10/8/2014 1/6/2015

08.00.44n Zoledronic Acid (Zometa®, Reclast®) 12/2/2014 1/1/2015

08.00.65h Pamidronate Disodium (Aredia®) for Intravenous Infusion 12/2/2014 1/1/2015

08.00.68e Ibandronate Sodium (Boniva®) for Intravenous Injection 12/2/2014 1/1/2015

08.09.11s Medicare Part B vs. Part D Crossover Drugs N/A 1/1/2015

11.15.17e Sacroiliac Joint and Paravertebral Facet Injection Nerve Blocks N/A 1/1/2015


Medical and claim payment policy activity Medicare Advantage business

The following pages list the policy activity for Medicare Advantage business that we have posted to our Medical Policy Portal from December 20, 2014 – January 23, 2015.

For the most up-to-date information about medical and claim payment policy activity for Medicare Advantage business, go to www.amerihealth.com/medpolicy, select Accept and Go to Medical Policy Online, and then select the Medicare Advantage tab. You can also view policy activity using the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

Note: Please refer to the January 2015 edition of Partners in Health UpdateSM for a complete list of Medicare Advantage policies that went into effect on January 1, 2015.

New policiesThe following Medicare Advantage policies have been newly developed to communicate coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with AmeriHealth.

Policy # Title Notifi cation date Effective dateMA08.006 Siltuximab (Sylvant™) N/A 1/15/2015

MA08.010 Programmed Cell Death Receptor-1 (PD-1) antagonists (e.g., Keytruda®) N/A 1/15/2015

Updated policies The following Medicare Advantage policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other procedures for doing business with AmeriHealth.


MA07.058aSleep Disorder Testing and Positive Airway Pressure Therapy


1/15/2015 2/15/2015

MA08.038a Oxaliplatin (Eloxatin®)Medical Necessity Criteria; General Description, Guidelines, or Informational Update

N/A 1/15/2015

MA08.044a Eculizumab (Soliris®)Medical Necessity Criteria; General Description, Guidelines, or Informational Update

N/A 1/15/2015

MA08.055a

Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)


N/A 1/15/2015

MA08.060a Pegloticase (Krystexxa®)Medical Necessity Criteria; General Description, Guidelines, or Informational Update

N/A 1/15/2015

MA09.007a Proton Beam Therapy


1/14/2015 4/1/2015



MA11.064a

Implantable Miniature Telescope™ (IMT) for the Treatment of End-Stage Age-Related Macular Degeneration (AMD)

Medical Necessity Criteria 1/15/2015 4/15/2015

MA12.001a Alternative Therapies and Complementary Medicine Medical Necessity Criteria N/A 1/14/2015

Reissued policiesThe following Medicare Advantage policies have been reviewed, and no substantive changes were made.



MA00.039 Never Events and Preventable Adverse Events 1/6/2015 1/9/2015

MA01.003 Organ and Tissue Recovery from a Cadaveric Donor and Associated Services 1/6/2015 1/9/2015

MA02.001 Hospice Care 1/6/2015 1/9/2015

MA02.002 Private Duty Nursing 1/6/2015 1/9/2015

MA05.001 High-Frequency Chest Wall Oscillation Devices 1/7/2015 1/9/2015

MA05.005 Automated External and Wearable Cardioverter Defi brillators 1/21/2015 1/23/2015

MA05.009 Cervical Traction Devices for In-home Use 1/7/2015 1/9/2015

MA05.019 Continuous Passive Motion (CPM) Devices in the Home Setting 1/7/2015 1/9/2015

MA05.055 Standing Frames 1/21/2015 1/23/2015

MA05.057 Upper-Limb Prostheses 1/21/2015 1/22/2015

MA07.014 Magnetic Pelvic Floor Stimulation (MPFS) 1/21/2015 1/23/2015

MA07.025 Intrauterine Systems (IUSs) (e.g., Mirena®, Skyla®) 1/6/2015 1/9/2015

MA08.029 Natalizumab (Tysabri®) 1/21/2015 1/23/2015

MA08.068 Brentuximab Vedotin (Adcetris®) 1/21/2015 1/23/2015

MA11.007 Islet Cell Transplantation 1/7/2015 1/9/2015

MA11.010 Abortion 1/6/2015 1/9/2015

MA11.021 Non-Surgical Spinal Decompression Therapy 1/6/2015 1/9/2015

MA11.046 Hair Transplants and Cranial Prostheses (Wigs) 1/21/2015 1/22/2015

MA11.054 Cataract Surgery 1/21/2015 1/23/2015

Coding updatesThe following Medicare Advantage policies have been reviewed and updated to add new and revised medical codes (e.g., ICD-9 and ICD-10 diagnosis codes; CPT® and HCPCS codes; revenue codes) and/or remove terminated medical codes.


MA00.012a Cast and Splint Applications and Associated Supplies Provided in the Offi ce Setting 1/2/2015 1/23/2015

MA00.016a Add-on Codes 1/2/2015 1/23/2015

MA03.003aModifi er 25: Signifi cant, Separately Identifi able Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service

1/2/2015 1/23/2015


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MA03.009a Modifi er 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period 1/2/2015 1/23/2015

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