Health. AmeriHealth New Jersey to Transition to Electronic Referral Submission

Transcription

1 P A R T N E R S Health in W O R K I N G T O G E T H E R F O R Q U A L I T Y H E A L T H C A R E INSIDE THIS ISSUE: MARCH 2005 ANNOUNCEMENTS Enhanced Provider Search Launching this Spring Restorative/Therapy Services Retrospective Review Benefit Clarifications for AmeriHealth (Delaware only) BILLING TIPS New 13-Position Member Identification Number Billing Requirement: Use Complete Member ID Number Avoid Claims Rejections FOR MEMBER S HEALTH Supporting Our Members, Your Patients: Connections SM Health Management Programs GET CONNECTED Do It All with NaviNet SM : A Tip to Streamline the NaviNet SM Preauthorization Request Process COMING IN 2005: AmeriHealth New Jersey to Transition to Electronic Referral Submission To maintain accuracy and speed of processing for the millions of transactions we complete yearly, in New Jersey, AmeriHealth HMO, Inc. and its affiliates (AmeriHealth) will be transitioning to an all-electronic format for encounters and referrals later this year. Look for more detail regarding our electronic encounter/referral initiative in next month s Partners in Health Update. To get connected to NaviNet SM, please call the ebusiness Provider Inquiry Line at (856) in New Jersey or complete our Online Inquiry Form at /providers/navinet. Investors in NaviMedix, Inc. include an affiliate of AmeriHealth, which has minority ownership interest in NaviMedix, Inc.

2 ANNOUNCEMENTS Enhanced Provider Search Launching this Spring This spring, AmeriHealth will launch an enhanced Provider Search that will be available to members via our secure member website ( and to providers via NaviNet SM. This enhancement includes comparative hospital and physician information from HealthGrades, Inc. a leading company providing health care quality ratings. As detailed in January Update, using the enhanced online Provider Search, members and providers will have access to a link to the HealthGrades Quality Ratings Suite, Restorative/Therapy Services Retrospective Review In early 2005, AmeriHealth will begin the retrospective review for ongoing restorative/therapy services (e.g., physical therapy, occupational therapy, spinal manipulation) cases.* Coverage for restorative/therapy services under AmeriHealth health benefit programs is provided for acute conditions when there is a reasonable likelihood of recovery or when significant improvement in function can be expected. These services are typically short-term, goal-directed treatment interventions. Examples include physical rehabilitation following surgery or the short-term treatment of neck or back injuries. Treatment focuses on prevention of recurrence, self-management strategies, and specific home care. comprised of two components: the Hospital Quality Guide and the Physician Quality Guide. The Hospital Quality Guide allows users to view and compare network hospital procedure-specific performance. The Physician Quality Guide offers descriptive information about physicians. For information on NaviNet SM and how to get connected, see the NaviNet SM article on page 5. Investors in NaviMedix, Inc. include an affiliate of AmeriHealth, which has minority ownership interest in NaviMedix, Inc. Coverage is not provided for restorative/therapy services to maintain or prevent deterioration of a chronic condition. If, as a result of retrospective review, AmeriHealth determines that restorative/therapy services provided to a member did not meet coverage criteria, AmeriHealth may adjust any payments made for future restorative/therapy services that are determined by retrospective review not to meet AmeriHealth s coverage criteria. * Please note: For NJ Small Employer Health members, the retrospective review will be based on medical necessity and not maintenance. March

3 Benefit Clarifications for AmeriHealth (Delaware only) Effective May 1, 2005, the following member benefit clarifications will be implemented for AmeriHealth HMO, POS, and PPO programs in Delaware: Cochlear Implants (HMO, POS, Flex HMO/POS/PPO): Coverage for medically necessary cochlear implants was added to align with the standard PPO benefit. In addition, hearing aid exclusion language was modified to clarify that cochlear electromagnetic devices are considered hearing aids and are not covered under the plan, unless the group purchased coverage for hearing aids. Please see the member s benefit information. Obesity Surgery (HMO, POS, PPO, Flex HMO/POS/PPO): Exclusion language was clarified to indicate that reversal, revision, and/or repeat of elective surgeries are not covered unless needed as a result of complications or true surgical failure. Precertification/Prior authorization is required. PET Scans (POS, PPO): Language was added to disclose precertification requirements for PET Scans. Alternative Therapies (HMO, POS, PPO, Flex HMO/POS/PPO): Exclusion language was added to clarify the exclusion of alternative therapies. Homebound (HMO, POS, PPO, Flex HMO/POS/PPO): Benefit language was clarified to define homebound status and that it is a requirement in order to have home health care covered. Cardiac Rehabilitation (PPO, Flex HMO/POS/PPO): Benefit information was modified to remove diagnosis/specific condition information and replace with medical necessity language to standardize the benefit with standard HMO and POS programs. Bone Density Testing (PPO, Flex PPO): Coverage was clarified for the preventive health schedule for routine osteoporosis screening. Coverage is provided to members age 65 or older. For more information on additional benefit clarifications, please see the Spring Clinical Update. If you have questions regarding these clarifications, please contact your Network Coordinator. Various policies may apply to these services and should be accessed at /providers under the Medical section. March

4 BILLING TIPS New 13-Position Member Identification Number March 2005 As you may know, various states have enacted laws to limit the use of a member s Social Security Number (SSN) on ID cards and other materials. As a result of this legislative trend, and to better protect member identity and privacy, AmeriHealth HMO, Inc., and its affiliates (AmeriHealth) have developed a non SSN-based identifier for members to be used on external communications to members, including member identification cards. The new Member Identification Number will consist of a 3-position alpha/numeric prefix, an 8-position ID number, along with a 2-position suffix, which defines a member of the family unit. Beginning in spring 2005, this new Member Identification Number is due to become effective and members will be issued new ID cards. As we finalize the details in the upcoming months, please look for more information in future editions of monthly Partners in Health Update. Please call Provider Services or your Network Coordinator with questions. New Member Identification Number (Effective Spring 05) 3-position alpha/numeric prefix + 8-position ID number + 2-position suffix = 13 positions Billing Requirement: Use Complete Member ID Number To facilitate claims processing, please include the complete member identification number as it appears on the member s ID card. For AmeriHealth PPO, AmeriHealth Traditional Medical, and Comprehensive Major Medical (CMM) members, please include the 3-position alpha/numeric claim router located at the Avoid Claims Rejections The performing provider ID number must be recorded on all claims in order to prevent rejection. This is a required data element in conjunction with HIPAA compliance and other requirements. HMO, POS, and PPO claims submitted without the identification number of the physician or other professional provider performing the procedure or service are being rejected and returned as non-clean claims and must be resubmitted with the necessary information. beginning of the member s ID number when submitting all claims. For HMO and POS, please note, the lab indicator (for example, A, H, L, M, N, T, or Q ) located on the front of HMO and POS ID cards should not be included in the member s ID number. HIPAA COMPLIANCE TESTING AND CONVERSION INSTRUCTIONS For assistance with testing and conversion to the HIPAA-compliant claims transaction 837, please contact the NaviMedix, Inc. HIPAA Conversion Team at (866) You may also contact the AmeriHealth ebusiness Help Desk at (215) or at claims.edi-admin@amerihealth.com. For information about registering for NaviNet SM, contact the ebusiness Provider Inquiry Line at (856) in New Jersey and (302) in Delaware, and leave a detailed message, or complete our Online Inquiry Form at /providers/navinet. For more information about NaviNet Claims SM, please contact NaviMedix, Inc. at (800) ext. 118, or visit the NaviNet Claims SM website at For providers who submit electronic claims through Highmark : If you have not yet converted to the HIPAA-compliant 837 claims transaction, before being able to test for conversion you must complete a new enrollment application at edi-services/edi_signup.html. 4

5 FOR MEMBER S HEALTH SUPPORTING OUR MEMBERS, YOUR PATIENTS: CONNECTIONS SM HEALTH MANAGEMENT PROGRAMS HELPING YOU AND YOUR PATIENTS MANAGE FIVE CHRONIC CONDITIONS (Asthma, CAD, CHF, COPD, and Diabetes) CONTACT THE CONNECTIONS SM PROGRAMS PROVIDER SUPPORT LINE AT (866) TO: Refer a member for Health Coaching. Ask questions or provide feedback. Request information regarding the SMART TM Registry. Request Connections SM posters for your office, referral pads, or copies of the Clinical Insights. Request patient information for the purposes of treatment or care coordination for your patient. GET CONNECTED A Connections SM Provider Service Specialist will return your call within two business days. DO IT ALL WITH NAVINET S M : A Tip to Streamline the NaviNet SM Preauthorization Request Process PROVIDING RESOURCES FOR YOU AND YOUR PATIENTS WITH END-STAGE RENAL DISEASE CONTACT THE CONNECTIONS SM KIDNEY PROGRAM AT (866) 303-4CKP [4257] TO: Refer a member on chronic outpatient dialysis to a Health Service Coordinator. Ask questions or provide feedback. Request individual member information. NaviNet SM users can now reduce the amount of time required for Preauthorization requests by utilizing the new Plan of Treatment and Additional Comments fields on the request form. These fields allow users to provide the answers to many of the common questions that the Precertification staff must ask. Any appropriate clinical data that would be helpful to complete a clinical review can be entered into these fields. The following are some examples of clinical data that should be included: Prior medical or surgical treatment. Side of body affected. Height/weight/BMI. By providing this information at the time of the request, users can reduce the need for follow-up phone calls to the Precertification staff and may see a quicker turnaround time for pending authorizations. Be sure to check the NaviNet SM Authorization Status Inquiry whenever a request is pending. The information displayed in the Authorization Status Inquiry is in real-time; therefore, as soon as the request has been reviewed and updated, it will be displayed on NaviNet SM. i NaviNet SM ebusiness Provider Inquiry Line Registration or (856) in New Jersey Questions (302) in Delaware Online Inquiry Form /providers/navinet? Technical NaviMedix, Inc. (888) Assistance 8:00 a.m. to 8:00 p.m., EST, for Existing Monday through Friday, and NaviNet SM Users 8:00 a.m. to 3:00 p.m., EST, Saturday Investors in NaviMedix, Inc. include an affiliate of AmeriHealth, which has a minority ownership interest in NaviMedix, Inc. March

6 TRADES ALLIED PRINTING UNION LABEL SCRANTON COUNCIL IMPORTANT RESOURCES PROVIDER INFORMATION and TOOLS WEB PAGE /providers PROVIDER MEDICAL POLICY WEB PAGE /medpolicy PROVIDER ELECTRONIC DATA INTERCHANGE SERVICES WEB PAGE /edi CORPORATE AND FINANCIAL INVESTIGATIONS DEPARTMENT Anti-Fraud and Corporate Compliance Hotline (866) /anti-fraud CREDENTIALING COMPLIANCE HOTLINE (866) /credentials PROVIDER SERVICES Policies/Procedures/Claims HMO (800) NJ (800) DE PPO (800) NJ (800) DE PHARMACY SERVICES Prescription Drug Authorization (888) Toll-Free Fax (888) Direct Ship Injectable (267) (888) Fax (215) Blood Glucose Meter Hotline (888) (option 2) PROVIDER SUPPLY LINE (800) HEALTH RESOURCE CENTER AmeriHealth Healthy Lifestyles SM (800) Precertification (800) CARE MANAGEMENT AND COORDINATION HMO Commercial (800) DE (800) NJ PPO (800) Case Management (800) DE (800) NJ Baby FootSteps (800) 598-BABY [2229] CONNECTIONS SM HEALTH MANAGEMENT PROGRAMS PROVIDER SUPPORT LINE (866) CONNECTIONS SM KIDNEY PROGRAM (866) 303-4CKP [4257] The AmeriHealth Partners in Health monthly Update is a publication of the Provider Communications department for the exchange of information and ideas among the AmeriHealth Provider community. Suggestions are welcome. Contact Information: Laura LeGower Managing Editor Elizabeth Derago Production Coordinator Provider Communications AmeriHealth 1901 Market Street, 35th Floor Philadelphia, PA Visit our website at View our online provider directories at. AmeriHealth products are offered by QCC Insurance Company d/b/a AmeriHealth Insurance Company, AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey. The third-party Web sites 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 presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefit plans. Members should refer to their benefit contract for complete details of the terms, limitations, and exclusions of their coverage /03 R 13

7 Updated Electronic and Paper Referral Forms In April 2005, we will be updating our NaviNet SM and paper versions of the AmeriHealth HMO Encounter/Referral Form. Paper users should continue to use existing paper stock. PCPs will no longer need to indicate the number of visits being authorized on the referral. Instead of the Initial Consult (no other services authorized), Evaluate and Follow-Up Number of Visits, and Evaluate and Treat (one visit) choices in the Services Requested section of the form, PCPs can now select either: Evaluate and provide follow-up care as needed (including outpatient hospital care only) for up to 90 days from the date of this referral. or Evaluate and provide follow-up care as needed including outpatient and inpatient hospital care, for up to 90 days from the date of this referral. Since PCPs no longer need to indicate a number of authorized visits on the updated form, the performing provider can now determine the number of visits that are medically appropriate for the member during the 90-day period. These selections also authorize the member to be seen by the referred provider in an office or hospital setting. Note: Certain services require preapproval. AmeriHealth will not pay for services requiring preapproval without the necessary preapproval. * Certain services require PRECERTIFICATION. AmeriHealth will not pay for services requiring pre-approval without the necessary PRECERTIFCATION. Radiology, Physical Therapy, Mental Health/Substance Abuse, and Laboratory must be referred to designated providers, except in New Jersey. In New Jersey, members may go to any participating provider with a referral and authorization by AmeriHealth. In Delaware, there are no designated Radiology providers. If the services requested are not to be provided at the PCP s designated site, please call the Care Management and Coordination department at to preauthorize the procedure before issuing an Encounter/Referral form. AmeriHealth HMO, Inc. AmeriHealth Insurance Company of New Jersey QCC Insurance Company d/b/a AmeriHealth Insurance Company

8 TRADES ALLIED PRINTING UNION LABEL SCRANTON COUNCIL AMERIHEALTH POS PLUS Quick Reference Guide AmeriHealth POS Plus: The Plus means NO referral required. Unlike standard POS plans, with AmeriHealth POS Plus, members NEVER need a referral to seek specialist care. While POS Plus members choose a primary care physician (PCP) from the AmeriHealth network, members may seek care directly from any PCP or specialist in the network. Please note: AmeriHealth PCPs are permitted to treat all AmeriHealth POS Plus members, including those who do not appear on their member rosters. Although PCPs are paid fee-for-service, PCPs with POS Plus members who are assigned to them can find their names listed separately at the end of the capitation roster. AmeriHealth POS Plus How the Plan Works Member Selects a Participating PCP from the AmeriHealth Network AmeriHealth POS Plus members receive the highest level of coverage by seeking care from an AmeriHealth participating provider. When AmeriHealth POS Plus members choose to visit a non-participating provider, the member will incur additional out-ofpocket costs. RX logo (if applicable) In-Network No referrals required Copayments/No Deductibles No paperwork for member Out-of-Network No referrals required Applicable Deductible/Coinsurance Claim filing may be required by member POS Plus members must select a PCP and may seek care from any PCP in the AmeriHealth network. QCC Insurance Company d/b/a AmeriHealth Insurance Company AmeriHealth HMO Inc. AmeriHealth Insurance Company of New Jersey POS Plus NO REFERRALS REQUIRED MEMBER, A Q FAMILY PRACTICE ASSOC PCP$20 SELRX ER$100 SD$40/80 RX: APP0000 NJ PARTNERS IN HEALTH UPDATE MARCH 2005 ENCLOSURE R 13 1 of 1