sm may 2015 - amerihealthprovcomm.amerihealth.com/.../$file/ah_pih_may2015.pdffrom the nca. articles...

updateSM

AmeriHealth encourages medical and behavioral health providers to work together page 12

ICD-10: The AmeriHealth guidelines for submitting authorizations and referrals page 5

Provider Automated System no longer available for migrated members page 4

May 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]

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 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

► Report prescription drug or health care fraud ► Provider Automated System no longer available for migrated members ► Overpayments for certain Medicare Advantage members identified and corrected

ICD-10 ► The AmeriHealth guidelines for submitting authorizations and referrals

NaviNet®

► Changes to NaviNet referral transactions coming in May

Billing ► Enforcing claims processing requirements ● Reminder: Billing requirements for billing multiple services ● Reminder: Important billing information for modifiers 25 and 59

Medical ► Changes to the Direct Ship Injectables Program ► Medical and claim payment policy activity posted from March 24 – April 24, 2015 ► CareCore’s radiation therapy criteria now in effect

Quality Management ► AmeriHealth encourages medical and behavioral health providers to work together

● Highlighting HEDIS®: Well-child visits in the third, fourth, fifth, and sixth years of life

Health and Wellness ● Suicide: A concern for all health care providers: Part 1 – An introduction to recognizing the role of all health care providers to address the issue of suicide

● Help your patients stay fit this spring with SilverSneakers®

● Help your heart failure patients avoid hospital readmission ● Encourage pregnant AmeriHealth members to register for Baby FootSteps®

ADMINISTRATIVE

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

Report prescription drug or health care fraudPrescription drug abuse is an ongoing problem. Not only does it have a significant societal impact, it drives up the cost of health insurance premiums. The AmeriHealth Corporate and Financial Investigations Department (CFID) is committed to reducing prescription drug fraud, waste, and abuse (FWA). Safeguards are in place to limit dispensing quantities and to make sure that the drug is medically necessary. Most of the drugs that are misused are opioid pain relievers with a high street value.

Addicted individuals will often use fraud to obtain these drugs. This includes:

● Doctor shopping. Visiting multiple doctors to obtain multiple prescriptions for the same complaint on a monthly basis.

● Pharmacy shopping. Using multiple pharmacies to fill different prescriptions for the same drug.

● Unnecessary ER visits. Unnecessary emergency room/department (ER) visits for the sole purpose of obtaining more drugs.

● Forgery. Forged prescriptions.

If you suspect prescription drug or health care fraud against you and/or AmeriHealth, we urge you to report it. All reports are confidential. You are not required to provide your name, address, or other identifying information.

Submitting a fraud reportYou have three options for submitting a fraud report:

● Web. Submit a report electronically using the Online Fraud & Abuse Tip Referral Form at www.amerihealth.com/antifraud.

● Phone. Call the confidential anti-fraud and corporate compliance toll-free hotline at 1-866-282-2707 (TTY: 1-888-789-0429).

● Mail. Write a description of your complaint, enclose copies of any supporting documentation, and mail it to:AmeriHealthCorporate & Financial Investigations Department1901 Market Street, 42nd FloorPhiladelphia, PA 19103

As a result of CFID’s efforts, last year $7.3 million was recovered in FWA-related claims and 18 fraud cases were referred to law enforcement or regulatory agencies. Multiples of the recovered amount were saved through the detection, prevention, and shutting down of improper payments and schemes. Many of these recoveries and referrals started with information someone provided to CFID. Please join us in the fight against health care and prescription drug fraud.

ADMINISTRATIVE


Provider Automated System no longer available for migrated membersAs previously communicated, the Provider Automated System is being retired in stages. Please read this notice carefully if you are still using the Provider Automated System, as your day-to-day operations may be affected.

Once an AmeriHealth member is migrated to the new operating platform, you can no longer use the Provider Automated System for that member. Therefore, the Provider Automated System is no longer available for any AmeriHealth Pennsylvania members or AmeriHealth New Jersey Medicare Advantage members, all of whom have been migrated to the new platform.

AmeriHealth New Jersey commercial members will be migrated to the new platform between September 1, 2015, and October 1, 2015. While you can currently use the Provider Automated System for these members for functions like eligibility or claims status, once an AmeriHealth New Jersey commercial member is migrated to the new platform, you will no longer be able to use the Provider Automated System for any functionality. You must use the NaviNet® web portal to retrieve this information.

Note: All participating providers are required to register for NaviNet. If you have not yet done so, go to www.navinet.net to sign up. If your office is currently NaviNet-enabled but would like training, call our eBusiness Provider Hotline at 215-640-7410 for AmeriHealth Pennsylvania or at 609-662-2565 for AmeriHealth New Jersey.

Overpayments for certain Medicare Advantage members identified and correctedSince 2011 the Centers for Medicare & Medicaid Services (CMS) has mandated a maximum out-of-pocket (MOOP) limit for all Medicare enrollees. The MOOP limit establishes an annual limit to the cost-sharing (e.g., deductibles, copayments, coinsurance) amount AmeriHealth 65® NJ HMO and AmeriHealth 65® Preferred HMO members have to pay out-of-pocket each year for medical services covered under Medicare Part A and Part B. The MOOP dollar amount is established annually by CMS and does not change during the course of a calendar year.

AmeriHealth identified an issue from 2014 where some AmeriHealth 65 NJ HMO and AmeriHealth 65 Preferred HMO member claims were erroneously processed with member cost-sharing for Part A and Part B medical services and drugs when their MOOP limit was met for the year. AmeriHealth has adjusted the affected claims, and providers who collected this additional member cost-sharing should work as expeditiously as possible to refund members accordingly.

If you have any questions, please contact Customer Service at 1-800-275-2583.

ICD-10


The AmeriHealth guidelines for submitting authorizations and referralsThis article contains a clarification for information related to the time frame in which AmeriHealth will begin accepting ICD-10 codes on authorizations and referrals.

In response to questions from providers regarding the rules on how AmeriHealth will handle authorization and referral requests for dates of services that occur on or after the ICD-10 compliance date of October 1, 2015, we are clarifying our position as outlined below.

Authorization and referral guidelines In regard to the submission of authorizations and referrals, AmeriHealth will follow its current process, which is to issue authorizations based on the request date.

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.

Time lines for professional, inpatient, and outpatient services

Note: Providers should not bill with ICD-10 codes before the October 1, 2015, compliance date. Claims using ICD-10 codes prior to October 1, 2015, will be rejected.

More informationFor the most up-to-date information on ICD-10 rules and guidelines, including frequently asked questions, please visit www.amerihealth.com/icd10 for AmeriHealth Pennsylvania and www.amerihealthnj.com/html/providers/claims_billing/coding.html for AmeriHealth New Jersey.

IMPORTANT Please note that the following information applies only to AmeriHealth and does not represent the guidelines of any other health plan. We encourage you to visit

the websites of each of the health plans your practice participates with to become familiar with their specific guidelines.

Attention! An update has been made to the content of this article.

Authorization/Referral submission date: Date of service: Code set to use:

Prior to and including September 30, 2015 Prior to and including September 30, 2015 ICD-9

Prior to and including September 30, 2015 On or after October 1, 2015 ICD-9

On or after October 1, 2015 Prior to and including September 30, 2015 ICD-10

On or after October 1, 2015 On or after October 1, 2015 ICD-10

NAVINET®


Changes to NaviNet Referrals transaction coming in MayLater in May, the Referrals transaction on the NaviNet® web portal will be upgraded to NaviNet Open, which is the new look and feel that NaviNet recently implemented for Plan Central. While the workflow remains similar, you will see the following changes specific to referral submissions and inquiries:

● Screens may look different. ● The procedure code field will not offer search capabilities/functionality. ● The search for a refer-to professional provider or facility will be modified.

A new user guide and webinar describing the transaction in greater detail will be available soon on our Provider News Center at www.amerihealth.com/pnc. Look for an update on NaviNet Plan Central. If you have any questions regarding these changes, call the eBusiness Hotline at 215-640-7410 for AmeriHealth Pennsylvania or at 609-662-2565 for AmeriHealth New Jersey.

Note: All participating providers are required to register for NaviNet. If you have not yet done so, go to www.navinet.net to sign up. If your office is currently NaviNet-enabled but would like training, call our eBusiness Provider Hotline.

BILLING


Enforcing claims processing requirementsAmeriHealth continues to enforce claims processing requirements since migrating to the new operating platform (i.e., claims processing for AmeriHealth Pennsylvania members and AmeriHealth New Jersey Medicare Advantage members). Note: AmeriHealth New Jersey commercial members will be migrated to the new platform by October 1, 2015. Our claims processing system ensures that claims contain the correct data before they are processed. Claims must have valid codes and all required fields completed in order to be processed on the new platform. The information below highlights the results of a recent analysis of post-migration rejection rates.

Common claim rejectionsBelow are the major reasons for most rejections and how to correct the errors:

● NPI and trading partner are not affiliated. The provider’s National Provider Identifier (NPI) and the trading partner are required to be linked in the new system; otherwise, the trading partner is not authorized to submit electronic claims on the provider’s behalf and the claims will reject. Contact your clearinghouse or billing vendor for instructions on how to affiliate. If you are your own trading partner, go to www.amerihealth.com/edi.

● NAIC code – Submit to the correct payer. Ensure that you submit claims with the appropriate NAIC code, as identified in the Payer Information column on our payer ID grids and in accordance with the member’s coverage. Refer to the payer ID grids at www.amerihealth.com/edi.

● Member not found: — Subscriber ID invalid. Providers must submit the most current member ID number based on the member’s coverage at the time of service. Refer to the article AmeriHealth Pennsylvania platform transition has been completed in the April 2015 edition of Partners in Health Update for more information on checking ID cards and verifying member eligibility at every visit.

— Names misspelled or name variations. A member’s name must be spelled as it appears on the member ID card. Variations in name spellings and punctuation will cause claims to reject (e.g., D’Angelo vs. Dangelo).

● Claim submitted without taxonomy code. The provider’s taxonomy code must be billed with the corresponding NPI and submitted at the billing provider level. Providers associated with more than one specialty group are required to submit the correct NPI and correlating taxonomy code to ensure correct claims processing. Sending claims with incorrect taxonomy codes could cause payment delays or cause claims to be paid incorrectly. These errors occur most frequently with mutli-specialty groups. Detailed information and examples on how to correctly submit taxonomy codes can be found in the article Guidelines for billing with taxonomy codes in the June 2014 edition of Partners in Health Update.

● Missing referring provider. The referring provider is required on all claims when the place of service is 81, a professional independent clinical lab.

● Missing procedure description. A service line description is required for all non-specific procedure codes submitted on a claim. Non-specific procedure codes include not otherwise classified [NOC]; unspecified; other; miscellaneous; prescription drug, generic; or prescription drug, brand name.

● Code set validations. Valid codes, including HCPCS, CPT®, diagnosis, and revenue codes and procedure code modifiers, are required for all claims. Submitted claims containing invalid codes or codes with termination dates effective prior to or on the date of service will not be processed.

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BILLING


Reminder: Billing requirements for billing multiple servicesAs previously communicated through Partners in Health Update and published in the Provider Manual for Participating Professional Providers, AmeriHealth requires that professional claims be billed on one CMS-1500 claim form or electronic 837P transaction when two or more services are performed for the same patient, by the same performing provider, and on the same date of service. The only exception would be when we specifically require services to be billed on separate claims based on an AmeriHealth policy (i.e., assistant or co-surgery claims).

Claims submitted otherwise are considered split-billed claims when there is no policy that requires billing on separate claims. More specifically, claims are considered split-billed when more than one claim is submitted for payment for two or more services performed for the same patient, by the same performing provider, and on the same date of service and there is no policy to support split-billing.

Some examples of split-billing include: ● two or more procedures or services performed by the same performing provider, on the same date of service, on the same patient, submitted on more than one claim form;

● services considered included in the primary services and procedures as part of the expected services for the codes billed on separate claim forms.

Providers must bill for all services performed on the same day for the same patient on a single claim form. Failure to do so prohibits the application of all necessary edits and/or adjudication logic when processing the claim. As a result, claims may be under- or over-paid and member liability may be under- or over-stated.

As a reminder, if more than one CMS-1500 claim form or electronic 837P transaction is received for services performed on the same patient, by the same performing provider, and on the same date of service as a previously submitted claim, and there is no policy to support split-billing, we will adjust all individually submitted claims to deny. Providers will be required to submit the split-billed services as a single, new claim for payment consideration.

To the extent that service(s) for which there is no policy to support split-billing is inadvertently omitted from a previously submitted claim, the previous claim should be corrected. To submit a corrected claim, please use the Claims Investigation transaction on the NaviNet® web portal. Please do not submit a separate claim for the omitted services, as that will create a split-billed claim and all individually submitted claims will be adjusted to deny.

Correctly submitting UB-04 claim forms with OPL and COB When a paper claim is submitted and Other Party Liability (OPL) or Coordination of Benefits (COB) is involved, it is imperative that all applicable fields are completed correctly on the UB-04 claim form, including the following:

● Field Location 54 (FL54). FL54 is a required field when the indicated payer (other insurance) has paid an amount to the provider towards this bill. Report “0.00” if there is no payment made by the health plan or payment was applied to the member’s coinsurance or deductible.

● Field Locations 39, 40, 41 (FL39, FL40, FL41). FL39, FL40, and FL41 are required fields when there is a value code and amount that applies to the claim, specifically where 1) Medicare is primary and 2) coinsurance or a deductible applies.

● Multi-page claims. Per the National Uniform Billing Committee (NUBC), all claim-level data must be reported on each page of the UB-04 claim form. Line-level data will be unique on each page of the claim, and total charges for the claim (FL47, line 23) should be reported only on the last page.

For more informationFor more information on claims processing, visit the EDI section of our website at www.amerihealth.com/edi. For information about submitting claims using the UB-04 claim form, please refer to the NUBC website at www.nubc.org.

If you have any questions related to conducting EDI business with AmeriHealth, please call Highmark EDI Operations at 1-800-992-0246. Highmark EDI Operations is available Monday through Friday, 8 a.m. to 5 p.m., ET.

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BILLING


Reminder: Important billing information for modifiers 25 and 59This is a reminder that as of January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) edits are applicable to claims submitted on the CMS-1500 claim form or through the 837P transaction. Please refer to our Commercial and Medicare Advantage claim payment policies on NCCI edits, which are available 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:

● Commercial: #00.01.56a: National Correct Coding Initiative (NCCI) Code Pair Edits; ● Medicare Advantage: #MA00.041: National Correct Coding Initiative (NCCI) Code Pair Edits.

The CMS NCCI tables (Column 1/Column 2) are composed of code pair edits. These code pair edits identify services that are a component of a more comprehensive code or two codes that should not be reported together. Procedure code pairs designated by CMS with an NCCI modifier indicator of 0 (zero) are not eligible to be reimbursed separately when reported on the same date of service for the same member when performed by the same provider. The NCCI edit identified in the CMS NCCI file for these procedure code pairs will be applied by AmeriHealth regardless of the presence of a modifier.

Modifiers 25 and 59Procedure code pairs designated by CMS with an NCCI modifier indicator of 1, when clinically appropriate, are eligible to be reported with an appropriate modifier for separate reimbursement. The most frequently used modifiers are 25 and 59.

● Modifier 25: Modifier 25 is required when a significant, separately identifiable Evaluation and Management (E&M) service is performed by the same physician on the same day of a procedure or other service. For example, if an E&M service was also performed on the same day as an administration of an immunization, the E&M service should be billed with the modifier 25.

● Modifier 59: Modifier 59 is required to indicate that a procedure or service is separate, distinct, or independent from other non-E&M services performed on the same day by the same individual.

For more informationFor more detailed information regarding the appropriate use of these modifiers, please visit 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:

● Modifier 25: — Commercial: #03.00.06l: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service;

— Medicare Advantage: #MA03.003a: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service.

● Modifier 59: — Commercial: #03.00.08c: Modifier 59: Distinct Procedural Service; — Medicare Advantage: #MA03.005: Modifier 59: Distinct Procedural Service.

Please refer to the CMS NCCI file for procedure code pair edits and the associated modifier indicators: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html.

MEDICAL


Medical and claim payment policy activity posted from March 24 – April 24, 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 Benefits Programs from March 24 – April 24, 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.

Changes to the Direct Ship Injectables Program The Direct Ship Injectables Program is a value-added program for physicians in the AmeriHealth network. Under this program, physicians can order certain high-cost specialty drugs that are:

● administered in the physician’s office; ● eligible for coverage under the member’s medical benefit.

Physicians who use this program do not have to pay for the drugs they order. All payments for pharmaceuticals are handled between AmeriHealth and our network of specialty drug vendors. AmeriHealth determines which contracted specialty drug vendor will fulfill the order once the request is approved.

Program changesAmeriHealth is making changes to the program, including the following:

● The program name has been changed to the Direct Ship Drug Program to support the addition of certain infusible drugs.

● Remicade® (infliximab) has been added to the Direct Ship Drug Program. To order Remicade®, physicians must complete the general Direct Ship Drug Request Form, which is available at www.amerihealth.com/directship, and fax it to the number at the bottom of the form.

● A downloadable list of drugs that can be ordered through this program is available on the Direct Ship Drug Program web page.

We are also in the process of establishing a new, dedicated fax line for Direct Ship Drug Program requests. We will communicate more about this change in future editions of Partners in Health Update.

To learn more about the Direct Ship Drug Program and its advantages to physicians, go to www.amerihealth.com/directship.

www.amerihealth.com/medpolicy


MEDICAL


CareCore’s radiation therapy criteria now in effect As previously communicated, providers are required to obtain precertification through CareCore National, LLC (CareCore) for non-emergent outpatient radiation therapy services for all commercial AmeriHealth Pennsylvania HMO and POS members. As of May 1, 2015, we transitioned to the use of CareCore Radiation Therapy Utilization Management Criteria when reviewing requests for radiation therapy services. For members under age 19, services requested will always be automatically approved; however, precertification through CareCore is still required to ensure accurate and timely claims payment.

Direct access through NaviNet®

As of May 1, 2015, the NaviNet web portal offers direct access to CareCore’s provider portal to streamline the process of obtaining precertification. Providers can select CareCore from the Authorizations transaction and a new window will open that sends providers directly to CareCore’s provider portal and allows initiation of the precertification process.

From this page, select the Request a clinical certification/procedure option. Within the Clinical Certification section, providers can identify themselves by using either NPI or TIN, along with last name, city, and ZIP. The search will return any referring provider associated with the information entered. Simply select the appropriate provider/address to proceed with the remainder of the precertification process.

Additional enhancements to NaviNet, including the ability to review finalized precertifications for radiation therapy services precertified by CareCore, have been postponed and will be announced in July.

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MEDICAL


Precertification guidelines The criteria that will be used as the basis for reviewing precertification requests are available on CareCore’s website at www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx.

In addition, Medical Policy #09.00.56a: Radiation Therapy Services includes a link to the criteria that CareCore will use to determine medical necessity for radiation therapy services as well as a complete list of procedure codes that require precertification. To view this policy, visit our Medical Policy portal at www.amerihealth.com/medpolicy. Select Accept and Go to Medical Policy Online, and then select the Commercial tab from the top of the page. Then type the policy name or number in the Search field.

Requesting precertification You can initiate precertification for non-emergent outpatient radiation therapy in one of the following ways:

● NaviNet. Select CareCore from the Authorizations transaction. ● Telephone. Call CareCore directly at 1-866-686-2649.

AmeriHealth encourages medical and behavioral health providers to work togetherAmeriHealth encourages providers to improve communication between behavioral health care providers and primary care physicians (PCP) in an effort to promote a cohesive plan of care for patients.

While communication between PCPs and behavioral health providers is slowly improving, there continues to be a large percentage of providers, both medical and behavioral health, who do not communicate about patient care. Information that PCPs may find helpful when they contact their patients’ behavioral health provider includes:

● Is the patient on any second-generation antipsychotics?

● Are there any special considerations regarding medication interactions? Has the patient had any side effects from medications?

● How is this affecting any medical complaints? If there is a chronic illness, does the patient have increased symptoms during times of stress?

● How can you coordinate appropriate tests to be ordered and results monitored?

PCPs must obtain patient consent to exchange patients’ personal information and discuss their mental health care. Please discuss with your patients the importance of having this information for their health and safety. When possible, provide your patients with a consent form they can sign so they are aware of the information that will be shared and can express their written consent.

AmeriHealth and its behavioral health delegate Magellan Healthcare are working on a document to improve communication between medical and behavioral health providers. To obtain a copy of the current PCP to Behavioral Health Provider Communication Form, as well as other tools and resources, visit our Worksheets, Forms, and Guides at www.amerihealth.com/providers/resources/worksheets.

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

QUALITY MANAGEMENT

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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. Go to www.amerihealth.com/providers/resources/hedis.html to view previously published Highlighting HEDIS® topics. If you have feedback or would like to request a topic, email us at [email protected].

QUALITY MANAGEMENT

HEDIS® definitionWell-child visits in the third, fourth, fifth, and sixth years of life: The percentage of members ages 3 – 6 who had one or more well-child visits with a primary care physician (PCP) during the measurement year.

Why this measure is importantThis measure looks at the use of routine check-ups for preschool and early school-age children. It assesses the percentage of children ages 3, 4, 5, and 6 who received at least one well-child visit with a PCP during the measurement year. Well-child visits during the preschool and early school years are particularly important. A child can be helped through early detection of vision, speech, and language problems. Intervention can improve communication skills and avoid or reduce language and learning problems. The American Academy of Pediatrics recommends annual well-child visits for children ages 2 – 6. — NCQA, HEDIS 2015 V1

Highlighting HEDIS®: Well-child visits in the third, fourth, fifth, and sixth years of life

Plan performanceThe chart below displays the rates for one or more well-child visits for children ages 3 – 6 over a four-year period, comparing the national average for commercial HMO/PPO plans vs. AmeriHealth HMO/PPO plans.

YearCommercial

National AmeriHealthHMO PPO HMO PPO

2013 74.3% 70.3% 82.1% 83.0%2012 72.9% 69.9% 81.2% N/A2011 72.5% 69.8% 82.7% N/A2010 71.6% 67.8% 82.1% N/A

As this chart demonstrates, AmeriHealth performs above the national average for both its HMO and PPO plans. The goal for AmeriHealth is to reach the national 90th percentile benchmark, which is currently at 87.4 percent and 84.9 percent for HMO and PPO plans, respectively.

— Source: 2014 State of Health Care Quality Report

Quick tips for improvement 9 Keep an active tracking system

to monitor yearly visits for each member.

9 Inform caregivers on the importance of well-visits.

9 Consider providing off-hours and weekend appointment times.

*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.

HEALTH AND WELLNESS


Historically, suicide has been a focus of those in the Behavioral Health specialty. Today, all health care professionals — not just those who work in Behavioral Health — are being asked to make suicide prevention a priority for the patients in their practice.

Suicide is the 10th leading cause of death in the United States, and according to the Centers for Disease Control and Prevention (CDC), there has been a steady increase in suicides each year since 1999.1 The two age groups with the most significant increase are ages 45 – 54 with a 5.8 percent increase and ages 55 – 64 with a 5.9 percent increase. This information indicates that this important health issue needs to be addressed.

Your role in assessing risk of suicideMagellan Healthcare and AmeriHealth are leading the way to support a safety-oriented culture for members receiving any health care services. This partnership is providing guidance that is evidence-based to assure ongoing quality of care.

Since we do not have definitive information to determine what makes a person suicidal, we need to rely on evaluating risk factors. The role of the health care provider is to evaluate the risk factors to determine interventions that can keep a person safe.

Social determinants include healthy connectedness. This is not just for the time the person spends in your office but reinforces the need for you to encourage the patient to use community resources.

Clinical risk factors include many of the reasons that the individual has come to seek care from both the primary care and behavioral health provider. Some of these issues may be pain, insomnia, anxiety, suicidal thoughts, making a plan, and feeling hopeless or like a burden. In addition, substance use/abuse and trauma are risk factors that need to be assessed. As we assess for suicide, all health care professionals need to explore any passive ideation as well as active suicidal ideation because they can be associated with morbidity.2

As we work towards a “Zero Suicide” goal, team effectiveness is crucial. Communication among all providers, the individual, and the individual’s support system can bring us closer to reaching this goal.

1 Centers for Disease Control: National Vital Statistics Report. Deaths Final Data for 2010. 61:4. May 8, 2013.2 Baca-Garcia E, Perez-Rodriguez MM, Oquendo MA, et al. Estimating risk for suicide attempt: are we asking the right questions?

Passive suicidal ideation as a marker for suicidal behavior. J Affect Disord. 2011;134(1-3):327-332.

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

We are pleased to introduce a new 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.

Part 1 – An introduction to recognizing the role of all health care providers to address the issue of suicide

Suicide: A concern for all health care providers

HEALTH AND WELLNESS


Help your patients stay fit this spring with SilverSneakers®

Spring is a perfect time of year to encourage your AmeriHealth New Jersey Medicare Advantage patients to go outside, enjoy some fresh air, and get some exercise. The warmer weather is great for walking, and with their Healthways SilverSneakers Fitness benefit, your patients can easily join a walking group led by a certified instructor. Just tell your patients to visit www.silversneakers.com or call 1-888-423-4632 (TTY: 711) Monday through Friday, 8 a.m. to 8 p.m. ET, to find a SilverSneakers FLEXTM walking group class that may be near them. This popular activity for older adults is a great way for your patients to socialize, have some fun, and enjoy the many health benefits of exercise.

On those rainy days when walking outside is not ideal, encourage your patients to visit a fitness location and get their walk in by using a treadmill. They can even meet with their Program AdvisorTM to set specific goals, take a tour of the location, and get an overview on how to use the equipment. Some fitness locations even offer walking tracks for those who want to try something different. And be sure to remind your patients that, through their benefit, they can use any of the more than 13,000 fitness locations nationwide as often as they’d like. We want them to work out when, where, and how they want!

Benefits of walkingAs your patients progress, remind them that faster walking can help them live longer and better. In fact, according to a study in the January 5, 2011, issue of The Journal of the American Medical Association (JAMA), older adults having a greater walking speed – or gait speed – was associated with increased length of survival.1

Study authors suggest several reasons why gait speed may predict survival. Walking requires energy, balance, and support and affects the heart, lungs, and circulatory, nervous, and musculoskeletal systems; therefore, those older adults who demonstrate increased speed may also exhibit overall well-being not present in those with slower gaits.

SilverSneakers offers many exercise optionsIf your patients want to try another form of exercise, SilverSneakers offers many options to help them get fit their way. From access to basic amenities like pools and weight equipment to group exercise classes, your patients have many choices. Note: Classes and amenities vary by location.

Help your patients spring into action with their SilverSneakers Fitness benefit offered by AmeriHealth at no additional cost for AmeriHealth 65® NJ HMO and AmeriHealth 65® Preferred HMO members.

1 JAMA and Archives Journals (January 5, 2011). Walking speed associated with survival in older adults. ScienceDaily. Retrieved January 27, 2011, from www.sciencedaily.com/releases/2011/01/110104161621.htm

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

SilverSneakers is a registered trademark of Healthways, Inc.

HEALTH AND WELLNESS


Help your heart failure patients avoid hospital readmissionAmeriHealth New Jersey offers a Hospital Readmission Prevention Program that targets members who have a primary or secondary diagnosis of heart failure (HF) or have conditions that increase their risk of developing symptoms of HF. The program helps patients learn self-care and aims to remove barriers to care. The ultimate goal of the program is to reduce avoidable hospitalizations and unnecessary utilization of both the emergency room/department (ER) and observation services.

Based on our predictive model that includes clinical and sociodemographic risk factors and medication history, we are able to identify members who are likely to be readmitted to the hospital.

AmeriHealth New Jersey is working with ReAdmission Solutions, LLC (RAS), a specialized company with a proven track record in patient navigation, care coordination, and remote monitoring technology. RAS will work with providers and their AmeriHealth New Jersey patients on a multi-faceted advanced disease management program that includes the following key components:

● scheduling and coordinating appointments and facilitating transportation through community resources, if available;

● continuous remote monitoring using advanced technology;

● home visits in accordance with the patient’s home health benefit plan.

In addition, a RAS clinical coordinator is available 24 hours a day, 7 days a week to answer questions for both patients and doctors. During their inpatient stay, clinical coordinators may also be available to assist patients who have been admitted to the hospital.

If you would like to refer a patient to the program, please contact RAS directly at 1-800-533-3755. If you have questions or suggestions about the program, please contact your network medical director.

HEALTH AND WELLNESS


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.

*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 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

March 24 – April 24, 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 March 24 – April 24, 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 Notification date Effective date

00.03.10Obstetrical Ultrasounds for Members enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) product

N/A April 1, 2015

05.00.76 Breast Pumps March 11, 2015 April 10, 2015

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 Notification date Effective date

00.01.25z

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

Medical Coding N/A April 8, 2015

00.01.55d

New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances

Coverage and/or Reimbursement Position; Medical Coding N/A April 8, 2015

00.03.07k

Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products


05.00.12f Manual Wheelchairs Medical Coding N/A April 22, 2015

07.00.09d Topical Oxygenation Medical Coding N/A April 8, 2015

07.00.14e Cold Laser Therapy General Description, Guidelines, or Informational Update N/A April 8, 2015

07.02.09c Ambulatory Blood Pressure Monitoring (ABPM)

Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

February 23, 2015 March 25, 2015

07.03.08e Neuropsychological Evaluation/Testing Medical Coding N/A March 25, 2015


March 24 – April 24, 2015 2


07.07.01i Routine Foot Care for Certain Medical Conditions

Medical Necessity Criteria; Medical Coding N/A March 25, 2015

08.00.08fRadioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (AmeriHealth New Jersey)


April 1, 2015 May 1, 2015

08.00.66i Bevacizumab (Avastin®)


April 20, 2015 May 20, 2015

08.00.78p Self-Administered Drugs Coverage and/or Reimbursement Position; Medical Coding N/A April 1, 2015

08.01.14c Radium Ra 223 dichloride (Xofigo®) Injection (AmeriHealth New Jersey)


April 1, 2015 May 1, 2015

08.01.18a Vedolizumab (Entyvio®) Medical Necessity Criteria March 25, 2015 June 23, 2015

09.00.24c Full-Body Computerized Tomography (CT) Scan Screening

General Description, Guidelines, or Informational Update N/A March 25, 2015

09.00.46o High-Technology Radiology Services Medical Coding April 8, 2015 May 8, 2015

09.00.49g Proton Beam Radiation Therapy (AmeriHealth New Jersey)

Coverage and/or Reimbursement Position; Medical Necessity Criteria

December 31, 2014May 1, 2015 Revised March 4, 2015

09.00.56a Radiation Therapy Services (AmeriHealth Pennsylvania)


April 1, 2015 May 1, 2015

11.00.06f Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring for Adults Medical Necessity Criteria April 23, 2015 July 22, 2015

11.01.02k Cochlear Implant



11.01.06bBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids

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

February 5, 2015 May 6, 2015

11.03.15h Gastric Electrical Stimulation (Enterra™), Gastric Pacing Medical Coding N/A April 8, 2015

11.06.04i Uterine Artery Embolization


N/A March 25, 2015

11.08.17eDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails



11.11.01g Evaluation and Treatment of Erectile Dysfunction (ED) Medical Necessity Criteria March 5, 2015 June 3, 2015

11.11.03d Cryosurgical Ablation of the Prostate Gland Medical Necessity Criteria N/A April 8, 2015

11.15.01n Spinal Cord Stimulation (Dorsal Column Stimulation)


N/A April 22, 2015

March 24 – April 24, 2015 3


11.15.16k Vagus Nerve Stimulation (VNS)


N/A April 1, 2015

11.15.20k Deep Brain Stimulation (DBS) Coverage and/or Reimbursement Position March 25, 2015 April 24, 2015

11.17.06i

Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)


March 9, 2015 April 8, 2015

12.01.01ab Experimental/Investigational Services Coverage and/or Reimbursement Position; Medical Coding March 2, 2015 April 1, 2015

12.05.01h Outpatient Diabetes Education and Self-Management Training

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

April 6, 2015 May 6, 2015

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

Policy # Title Reissue effective date

Reissue published date

05.00.42f Patient Lifts April 15, 2015 April 15, 2015

05.00.43e Seat Lift Mechanisms April 15, 2015 April 15, 2015

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

07.03.03f Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD) April 15, 2015 April 15, 2015

07.06.03b Bioimpedance for the Detection of Lymphedema April 1, 2015 April 1, 2015

11.01.01i Otoplasty April 15, 2015 April 15, 2015

11.02.06j Catheter Ablation of Cardiac Arrhythmias April 15, 2015 April 16, 2015

11.08.08f Chemical Peels April 1, 2015 April 1, 2015

11.15.03g Insertion of Implantable Infusion Pumps April 1, 2015 April 1, 2015

11.16.07 Bronchial Thermoplasty April 15, 2015 April 16, 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 date

00.03.02s Diagnostic Radiology Services Included in Capitation January 1, 2015

February 6, 2015 Revised March 18, 2015 and April 16, 2015

00.06.02n Preventive Care Services April 1, 2015 April 6, 2015

08.00.92m Coagulation Factors for Hemophilia April 1, 2015 March 20, 2015

08.00.93c C1 Esterase Inhibitors: Cinryze®, Berinert®, and Ruconest® April 1, 2015 April 1, 2015

08.01.04j Preventive Immunization February 2, 2015 April 13, 2015

March 24 – April 24, 2015 4

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

Archived policiesAmeriHealth has determined that it is no longer necessary for the following commercial policy to remain active.

Policy # Title Notification date Archive effective date

11.15.11b Treatment for Hyperhidrosis (Nonpharmacologic) March 11, 2015 April 10, 2015

March 24 – April 24, 2015 5

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 March 24 – April 24, 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.

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

Policy # Title Notification Effective date

MA00.007Obstetrical Ultrasounds for members enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) product

N/A April 1, 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.

Policy # Title Type of policy change Notification Effective date

MA00.005a Experimental/Investigational Services

Coverage and/or Reimbursement Position; Medical Coding March 11, 2015 April 10, 2015

MA00.010b

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


MA00.030b

Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products


MA00.043b

New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances


MA05.047aTreatment of Obstructive Sleep Apnea (OSA) and Primary Snoring in Adults

Coverage and/or Reimbursement Position April 23, 2015 July 22, 2015

MA07.009a Routine Foot Care for Certain Medical Conditions

Medical Necessity Criteria; Medical Coding N/A March 25, 2015

MA07.011a Topical Oxygenation Medical Coding N/A April 8, 2015

MA07.036a Cold Laser Therapy Medical Necessity Criteria N/A April 8, 2015


March 24 – April 24, 2015 6

Policy # Title Type of policy change Notification Effective date

MA07.038a Neuropsychological Evaluation/Testing Medical Coding N/A March 25, 2015

MA07.045a Microvolt T-Wave Alternans (MTWA) Medical Necessity Criteria N/A March 25, 2015

MA08.007a Medicare Part B vs. Part D Crossover Drugs


MA08.014a Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®)

General Description, Guidelines, or Informational Update April 1, 2015 May 1, 2015

MA08.069b Radium Ra 223 Dichloride (Xofigo®) Injection

General Description, Guidelines, or Informational Update April 1, 2015 May 1, 2015

MA08.072a Bevacizumab (Avastin®)

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

April 20, 2015 May 20, 2015

MA09.002a High-Technology Radiology Services Medical Coding April 8, 2015 May 8, 2015

MA09.007a Proton Beam Therapy Coverage and/or Reimbursement Position; Medical Necessity Criteria January 14, 2014

May 1, 2015 Revised March 4, 2015

MA09.012aFull-Body Computerized Tomography (CT) Scan Screening

General Description, Guidelines, or Informational Update N/A March 25, 2015

MA11.004a

Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

Coverage and/or Reimbursement Position; Medical Coding March 9, 2015 April 8, 2015

MA11.014aDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails

General Description, Guidelines, or Informational Update February 23, 2015 March 25, 2015

MA11.019a Vagus Nerve Stimulation (VNS)Medical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update

N/A April 1, 2015

MA11.022a Cryosurgical Ablation of the Prostate Gland Medical Necessity Criteria N/A April 8, 2015

MA11.031a Spinal Cord Stimulation (Dorsal Column Stimulation)


N/A April 22, 2015

MA11.039a Cochlear ImplantationMedical Necessity Criteria; Medical Coding; General Description, Guidelines, or Informational Update


MA11.045a Uterine Artery Embolization

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

January 28, 2015 March 25, 2015

MA11.049a

Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids

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

February 5, 2015 May 6, 2015

MA11.064a

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

Medical Necessity Criteria January 15, 2015 April 15, 2015

MA11.079a Evaluation and Treatment of Erectile Dysfunction (ED) Medical Necessity Criteria March 5, 2015 June 3, 2015

March 24 – April 24, 2015 7

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

Policy # Title Reissue effective date

Reissue published date

MA05.011 Seat Lift Mechanisms April 15, 2015 April 16, 2015

MA05.026 Manual Wheelchairs April 15, 2015 April 16, 2015

MA05.031 Patient Lifts April 15, 2015 April 16, 2015

MA05.032 Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices April 1, 2015 April 1, 2015

MA07.052 Bioimpedance for the Detection of Lymphedema April 1, 2015 April 1, 2015

MA10.007 Speech Therapy April 15, 2015 April 16, 2015

MA11.006 Bronchial Thermoplasty April 15, 2015 April 16, 2015

MA11.058 Otoplasty April 15, 2015 April 16, 2015

MA11.060 Catheter Ablation of Cardiac Arrhythmias April 15, 2015 April 16, 2015

MA11.103 Chemical Peels April 1, 2015 April 1, 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.

Policy # Title Effective date Published date

MA00.027a Diagnostic Radiology Services Included in Capitation January 2, 2015

February 6, 2015 Revised March 18, 2015 and April 16, 2015

MA08.004b Coagulation Factors for Hemophilia April 1, 2015 March 20, 2015

MA08.051a C1 Esterase Inhibitors: Cinryze®, Berinert®, and Ruconest® April 1, 2015 April 1, 2015

Archived policiesAmeriHealth has determined that it is no longer necessary for the following Medicare Advantage policies to remain active.

Policy # Title Notification date Archive effective date

MA06.016 Heartsbreath Test for Heart Transplant Rejection March 25, 2015 April 24, 2015

MA11.094 Treatment for Hyperhidrosis (Nonpharmacologic) March 11, 2015 April 10, 2015

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.

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