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Provider Newsletter

August 2019NJ-NL-0299-19

August 2019

Table of ContentsMedicaid:Important IRS tax update Page 2

Changes to medical necessity criteria: Amerigroup Community Care adopts the Anthem Medical Policies for home care in New Jersey effective July 1, 2019 Page 2

Pharmacy management information Page 2

Update your information Page 2

Amerigroup Community Care Provider Incentive Program: Providers can earn more money Page 3

Long-acting reversible contraceptives Page 3

New service types added to Availity Page 3

Prepayment clinical validation review process Page 4

Unspecified diagnosis code update Page 4

AIM Specialty Health® programs may require documentation Page 4

Coming soon: electronic attachments Page 5

Normal newborn diagnosis-related group claims processing update Page 6

Medical Policies and Clinical Utilization Management Guidelines update Page 7

Prior authorization requirements Page 8

Medicare Advantage:Medicaid articles also applicable to Medicare Advantage Page 9

Special needs plans - provider training required Page 9

Notice of change in Medicare Advantage non-PCP reimbursement status Page 10

Reimbursement Policies:Drug Screen Testing Page 11

Emergency Department: Level of Evaluation and Management Services Page 11

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Medicaid

Important IRS tax update

Effective June 1, 2019, Amerigroup Community Care will begin to collect backup withholdings of 24 percent from all providers who have been nonresponsive to First and Second B Notices, per Internal Revenue Service (IRS) regulations.

If you have received these notices or begin to receive backup withholding, contact our 1099 Tax Reporting department immediately via:

� Telephone: 1-888-246-4893. � Fax: 1-805-557-6540. � Email: 1099dept@anthem.com.

NJPEC-1784-19

Pharmacy management information

Need up-to-date pharmacy information?Log in to our provider website to access our formulary, prior authorization forms, Preferred Drug List and process information.

Have questions about the formulary or need a paper copy? Call our Pharmacy department at 1-800-454-3730. Pharmacy technicians are available Monday-Friday from 8 a.m.-5 p.m.

Our Member Services representatives serve as advocates for our members. To reach Member Services, please call 1-800-600-4441 (TTY 711).NJ-NL-0282-19

Update your information

We continually update our provider directories to ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice — including updating your address and/or phone number, adding or deleting a physician from your practice, closing your practice to new patients, etc. — please notify us by sending all changes, including effective date, on practice letterhead to: Amerigroup Community Care101 Wood Ave. South, Eighth Floor,Iselin, NJ 08830

Thank you for your help and continued efforts in keeping our records up to date.NJ-NL-0282-19

Changes to medical necessity criteria: Amerigroup Community Care adopts the Anthem Medical Policies for home care in New Jersey effective July 1, 2019

Effective July 1, 2019, Amerigroup will transition from using InterQual® Level of Care Criteria to Anthem Medical Policies to review prior authorization requests for home care, including

home occupational therapy, physical therapy, speech therapy and home health aides.

Amerigroup will transition from using the InterQual Home Care Criteria to using the Clinical Utilization Management Guideline Home Health, CG-MED-23.

All acute rehabilitation inpatient care and skilled nursing inpatient care will continue to be reviewed for medical necessity using InterQual Level of Care Criteria.NJ-NL-0277-19

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Long-acting reversible contraceptives

Intrauterine devices (IUDs) do not require prior authorization (PA). Providers have the option to buy and bill Amerigroup Community Care or order for our members.

To obtain Kyleena, Liletta, Mirena, Skyla or Nexplanon, prescriptions may be submitted to CVS Specialty Pharmacy. Call 1-877-254-0015 and submit the prescription electronically or fax the prescription along with a copy of the member’s ID card to 1-877-287-7226.

To obtain Paragard T 380-A IUD, please visit www.paragardbvsp.com, and download the Patient Authorization and Referral Form. Please note that the member will need to sign the Patient Authorization section. Fax the form along with a copy of the member’s ID card to 1-855-215-5315. For assistance, please call Paragard Access Solutions at 1-877-PARAGARD (1-877-727-2427). NJ-NL-0287-19

Amerigroup Community Care Provider Incentive Program: Providers can earn more money

Amerigroup is excited to announce we have added new measures to our existing Provider Incentive Program (PIP), effective July 1, 2019. The Division of Medical Assistance and Health Services continues to invest in physician rates for the state fiscal year 2020 (ending June 30, 2020), and Amerigroup will continue to distribute these Medicaid funds through the PIP. The additional measures are related to member engagement, additional preventive care and hypertension. Existing measures related to general wellness, women’s health and basic diabetes care still apply. We encourage you to take advantage of our robust program. For more information or assistance, contact your local Provider Relations representative or call Provider Services at 1-800-454-3730.NJ-NL-0266-19

New service types added to Availity

Enhancements have been made to the Availity Portal that will now allow you to access more service types when using the Eligibility and Benefits Inquiry tool and will also allow us to share even more valuable information with you electronically.

You may have already noticed new additions to service types, including:

� Medically related transportation. � Long-term care. � Acupuncture. � Respite care. � Dermatology. � Sleep study therapy

(found under diagnostic medical).

� Allergy testing.

Note, although there is an extensive list of available benefit types available when submitting an eligibility and benefits request, these types do vary by payer.

Here are some important points to remember when selecting service types:

� The benefit/service type field is populated with the last benefit type you selected. If you don’t see a specific benefit in the results, submit a new request and select the specific benefit type/service code.

� You have the ability to inquire about 50 patients at one time using the Add Multiple Patients feature.

NJ-NL-0268-19

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AIM Specialty Health programs may require documentation

Currently, providers submit various pre-service requests to AIM Specialty Health® (AIM). As part of our ongoing quality improvement efforts, for outpatient diagnostic imaging services, cardiac procedures and sleep studies. AIM may request documentation to support the clinical appropriateness of certain requests.

When requested, providers should verify information by submitting documentation from the medical record and/or participating in a pre-service consultation with an AIM physician reviewer. If medical necessity is not supported, the request may be denied as not medically necessary.NJ-NL-0275-19

Unspecified diagnosis code update

Amerigroup Community Care previously communicated that as of July 1, 2018, we now require unspecified diagnosis codes to be used only when an established diagnosis code does not exist to describe the diagnosis for our members. Our goal is to align with ICD-10-CM requirements, using more specific diagnosis codes when available and appropriate. This includes codes that ICD-10-CM provides with laterality specifying whether the condition occurs on the left, right or is bilateral. The target effective date has been delayed for implementing the corresponding code edit. However, providers are encouraged to ensure their billing staff is aware of the required specificity in reporting ICD-10-CM diagnosis codes to prevent future denials.

Amerigroup will be sending out a follow-up article to inform providers of when to expect this requirement to go-live and any additional details for the changes made.NJ-NL-0262-19

Prepayment clinical validation review process

Effective with dates of service on or after September 5, 2019, Amerigroup Community Care will update our audit process for claims with modifiers used to bypass claim edits. Modifier reviews will be conducted through a prepayment clinical validation review process. Claims with modifiers such as -25, -59, -57, LT/RT and other anatomical modifiers will be part of this review process.

In accordance with published reimbursement policies that document proper usage and submission of modifiers, the clinical validation review process will evaluate the proper use of these modifiers in conjunction with the edits they are bypassing (such as NCCI). Clinical analysts who are registered nurses and certified coders will review claims pended for validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit.

If you believe a claim denial should be reviewed, please follow the applicable provider appeal process (outlined with the denial notification) and include medical records that support the usage of the modifier applied when submitting your appeal.NJ-NL-0261-19

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Coming soon: electronic attachments

As we prepare for the potential regulatory-proposed standards for electronic attachments, Amerigroup Community Care will be implementing X12 275 electronic attachment transactions (version 5010) for claims.

Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reducing processing time overall.

Amerigroup and Availity will pilot electronic data interchange batch electronic attachments with previously selected providers. Both solicited and unsolicited attachments will be included in our pilots.

Attachment types

Solicited attachments: The provider sends a claim, and the payer determines there is not enough information to process the claim. The payer will then send the provider a request for additional information (currently done via letter). The provider can then send the solicited attachment transaction, with the documentation requested, to process the claim.

Unsolicited attachment: When the provider knows that the payer requires additional information to process the claim, the provider will then send the X12 837 claim with the Paper Work Included segment tracking number. Then, the provider will send the X12 275 attachment transaction with the additional information and include the tracking number that was sent on the claim for matching.

What you can do As we prepare for this change, you can help now by having conversations with your clearinghouse and/or electronic health care records vendor to determine their ability to set up the X12 275 attachment transaction capabilities.

In addition, you should be on the lookout for additional information and details about working with Amerigroup and Availity to send attachments via electronic batch.NJ-NL-0278-19

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Normal newborn diagnosis-related group claims processing update

Effective November 1, 2019, Amerigroup Community Care will update the claims processing system to ensure accurate payment of newborn claims in accordance with New Jersey normal newborn diagnosis-related group (DRG) requirements and our inpatient authorization requirements.

All newborn inpatient stays must have sufficient documentation provided to support an admission to an area beyond the newborn nursery, such as a neonatal intensive care unit (NICU) or for the higher level of care associated with the more complex newborn DRG. Documentation to support the higher level admission includes authorization or medical records.

Failre to provide the appropriate documentation will result in the claim being processed based on the normal newborn rate. Please note that current authorization guidelines for normal newborn and higher level of care baby inpatient stays will be applied.

What is the impact of this change? � Newborn claims billed with higher level of care newborn DRG codes (see Tables A and B) must have the

required documentation on file. If the required documentation is not on file, the claim will be processed based on the normal well-newborn DRG rate.

� Documentation is required for reimbursement of non-normal newborn care or an inpatient stay beyond the normal well-newborn period or admission to an NICU.

� When newborn claims are submitted with only newborn care revenue codes (170 and 171) and there is no authorization for services provided for a higher level of care to support the higher level of care DRG, the claims will automatically be paid down to the normal newborn rate.

Explanation of Payment codeBased on the above, we have implemented a new explanation (EX) code A 59 (DRG billed does not match the revenue code submitted). This code will appear on your Explanation of Payment when a claim is billed with a higher level of care newborn DRG code and the required authorization or medical record for the higher level of care is not on file.

You may appeal your request for payment of the higher acuity DRG by submitting the appropriate supporting clinical documentation. Please follow the normal appeal process detailed in our provider manual, which is available online at https://providers.amerigroup.com/NJ.

Read more online.

NJ-NL-0129-18

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Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

To view a guideline, visit https://medicalpolicies.amerigroup.com/am_search.html.

Updates: � MED.00110 — Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and

Soft Tissue Grafting was revised to add bioengineered autologous skin-derived products (e.g., SkinTE) as investigational and not medically necessary.

� MED.00126 — Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders was revised to add Nasal Nitric Oxide as investigational and not medically necessary in the diagnosis and monitoring of asthma and other respiratory disorders.

� SURG.00037 — Treatment of Varicose Veins (Lower Extremities) was revised: � To replace “nonsurgical management” with “conservative therapy” in the medically necessary criteria � To add sclerotherapy used in conjunction with a balloon catheter (e.g., catheter-assisted vein

sclerotherapy [KAVS] procedure) as investigational and not medically necessary � TRANS.00035 — Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders,

Autoimmune, Inflammatory and Degenerative Diseases (previous title: Mesenchymal Stem Cell Therapy For Orthopedic Indications)

� Includes the revised position statement: “Mesenchymal stem cell therapy is considered investigational and not medically necessary (INV&NMN) for the treatment of joint and ligament disorders caused by injury or degeneration as well as autoimmune, inflammatory and degenerative diseases.”

� Expands the document’s scope to address non-FDA approved uses of mesenchymal stem cell therapy � The following AIM Specialty Health® updates took effect on January 24, 2019:

� Advanced Imaging � Imaging of the Heart � Imaging of the Head and Neck

NJ-NL-0276-19

Read more online.

� Arterial Ultrasound � Joint Surgery � Sleep Disorder Management Diagnostic and Treatment

Medical Policies On January 24, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup Community Care. View the full update online for a list of the policies.

Clinical UM Guidelines On January 24, 2019, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. These guidelines were adopted by the medical operations committee for Amerigroup members on March 28, 2019. View the full update online for a list of the guidelines.

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Prior authorization requirements

Hyperbaric oxygen and supervision of hyperbaric oxygen therapy

Effective October 1, 2019, prior authorization (PA) requirements will change for hyperbaric oxygen and supervision of hyperbaric oxygen therapy to be covered by Amerigroup Community Care.

PA requirements will be added to the following:

� Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval (G0277)

� Physician attendance and supervision of hyperbaric oxygen therapy, per session (99183)

NJ-NL-0283-19

Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

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

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the Precertification Lookup Tool at https://www.availity.com via https://providers.amerigroup.com/NJ. Contracted and noncontracted providers who are unable to access the Availity Portal can call Provider Services at 1-800-454-3730.

Durable medical equipment

Effective December 1, 2019, prior authorization (PA) requirements will change for the codes listed below. The listed codes will require PA by Amerigroup Community Care for NJ FamilyCare members.

PA requirements will be added to the following: � All lower extremity prosthesis — shank foot system with

vertical loading pylon (L5987) � Gait trainer, pediatric size — anterior support, includes all

accessories and components (E8002) � Wheelchair, pediatric size — tilt-in-space, folding, adjustable,

without seating system (E1234) � Wheelchair, pediatric size — tilt-in-space, rigid, adjustable,

without seating system (E1233) � Transport chair, pediatric size (E1037) � Multi-positional patient transfer system with integrated seat,

operated by care giver (E1035) � Wheelchair accessory — ventilator tray, gimbaled (E1030) � Water circulating heat pad with pump (E0217)

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Coverage provided by Amerigroup Inc.

Medicare Advantage

New service types added to AvailityView the article in the Medicaid section.NJ-NL-0268-19

Prepayment clinical validation review process View the article in the Medicaid section.NJ-NL-0261-19

Unspecified diagnosis code update View the article in the Medicaid section.NJ-NL-0262-19

AIM Specialty Health programs may require documentationView the article in the Medicaid section.NJ-NL-0275-19

Coming soon: electronic attachmentsView the article in the Medicaid section.NJ-NL-0278-19

Special needs plans — provider training required

Amerigroup Community Care offers special needs plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNPs include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums. As you are aware, CMS regulations protect SNP members from balance billing.

Providers who are contracted for SNPs are required to take annual training to stay current on plan benefits and requirements, including coordination-of-care and model-of-care elements. Providers contracted for our SNPs received notices in the first quarter of 2019 containing information for online, self-paced training through our training site hosted by SkillSoft. Each provider contracted for our SNPs is required to complete this annual training and select the attestation stating they have completed the training. Attestations can be completed by individual providers or at the group level with one signature.

AGPCRNL-0033-19

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Notice of change in Medicare Advantage non-PCP reimbursement status

Amerigroup Community Care has evaluated its Medicare Advantage network to improve quality of care and efficiencies in the oversight of our networks. CMS regulations support Medicare Advantage plans’ ongoing evaluation of their provider networks to ensure that plans are able to manage the cost and quality of care while maintaining access to care for members.

Our review of your file indicates that you are listed in our Medicare Advantage directory as a PCP. This article serves as notice of required adherence to the following standards:

� Members must be able to access their PCP 24 hours a day, 7 days a week. � As the member’s health care manager, the PCP is responsible for providing or arranging health care

services 24 hours a day, 7 days a week. An answering machine does not suffice as access to the provider. � You must also have a method to inform Amerigroup members about office hours and how to obtain care

after office hours.

When off-duty or otherwise unavailable, the PCP must arrange for back-up coverage by a network physician so that appropriate medical care is available to members at all times. If the designated backup network physician is contracted under the PCP’s agreement and bills under the same tax identification number, no backup arrangement is required. If not, the PCP must inform Amerigroup of the name, telephone number and address of the physician responsible for providing backup services to patients.

The PCP should contact Amerigroup to ensure that our records reflect your plan for patient coverage. If Amerigroup does not have complete records that you are the covering physician as required above, any claim you submit will deny unless an exception applies. These exceptions are described in further detail in the Provider Manual. In addition, if you regularly see Amerigroup members who have not chosen you as their assigned PCP, your claims may deny under this policy until the member selects you as their assigned PCP. The PCP should contact Amerigroup Designated Service Unit (DSU) at 1-866-805-4589 8:00 a.m. to 8:00 p.m. EST, Monday to Friday if the designated back-up changes.AGPCRNL-0039-19

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Reimbursement Policies

New PolicyDrug Screen Testing(Policy 19-001, effective 10/01/19)

Effective October 1, 2019, Amerigroup Community Care will allow separate reimbursement for definitive drug testing of 1-7 drug classes. Definitive drug testing for eight or more drug classes will not be separately reimbursed when performed on the same date of service as presumptive testing.

Definitive drug testing may be done to confirm the results of a negative presumptive test or to identify substances when there is no presumptive test available. Provider’s documentation and member’s medical records should reflect that the test was properly ordered and support that the order was based on the result of the presumptive test.

In the event a reference lab (POS = 81) performs both presumptive and definitive tests on the same date of service, records should reflect that the ordering/treating provider issued a subsequent order for definitive testing based on the results of the presumptive tests.

For additional information, refer to the Drug Screen Testing reimbursement policy at https://providers.amerigroup.com/NJ.NJ-NL-0259-19

New PolicyEmergency Department: Level of Evaluation and Management Services(Policy 19-002, effective 09/01/19)

Effective September 1, 2019, Amerigroup Community Care classifies the intensity/complexity of facility emergency department (ED) interventions used for services rendered with an evaluation and management (E&M) code level. E&M services will be reimbursed based on this classification at the highest E&M level supported on the claim. Facilities must utilize appropriate CPT/HCPCS and revenue codes for all services rendered during the ED encounter.

Please refer to the Emergency Department: Level of Evaluation and Management Services reimbursement policy for additional details at https://providers.amerigroup.com.

Providers who feel that the level of reimbursement should be reconsidered can file a claims dispute in accordance with the terms of their contract. Claims disputes require a statement as to why the intensity/complexity would require a different level of reimbursement as well as the medical records, which should clearly document the facility interventions performed and referenced in that statement.NJ-NL-0279-19