Provider Newsletterhttps://providers.amerigroup.com/��

August 2018MD-NL-0135-18

August 2018

Table of ContentsBilling guidelines for developmental and mental health screening and assessment in primary care

Page 2

Coding Spotlight — Obesity Page 2

Normal newborn diagnosis-related group claims processing update Page 2

Wound care treatment request update Page 3

Review of information on file for your practice Page 3

The Interactive Care Reviewer tool is available — Start using today! Page 4

More than a score: working together to achieve better health outcomes while meeting HEDIS measures

Page 5

Clinical Practice Guidelines notification Page 6

Reminder from the Operations department regarding member appeals Page 6

Members’ Rights and Responsibilities Statement Page 6

Important information about utilization management Page 7

Electronic Data Interchange migration to Availity Page 7

Medical Policies and Clinical Utilization Management Guidelines updates Page 8

Obstetric imaging precertification clarification Page 9

New HealthChoice Benefit Requirement Audiology Services for Children and Adults

Page 10

Behavioral Health Corner Page 11

Prior authorization requirements Page 12

Reimbursement Policy:Medical Recalls Page 13

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Billing guidelines for developmental and mental health screening and assessment in primary care

Amerigroup Community Care would like to inform you about billing guidelines for developmental and mental health screenings and assessment in primary care.

Recommendations from the Maryland Healthy Kids Preventive Health Schedule, examples of acceptable standardized tools, code-specific billing guidelines and limitations are outlined in the provider update.MD-NL-0133-18

Normal newborn diagnosis-related group claims processing update

Effective November 1, 2018, Amerigroup Community Care will update the claims processing system to ensure accurate payment of newborn claims in accordance with Maryland 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.

Failure 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.

For more information, reference the full provider update. MD-NL-0110-18

Coding Spotlight — Obesity

The obesity epidemic is a serious issue in the United States. The obesity rate is rising. Obesity has significant health consequences, contributing to increased rates in several diseases, including metabolic syndrome, high blood pressure, diabetes, heart disease, high blood cholesterol, sleep disorders and cancers.

For detail information on obesity HEDIS® measurements and coding, please view the full update on our website.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).MD-NL-0126-18

Provider Manual update

The latest update to the Provider Manual is now available online. To view the manual, visit our provider website (https://providers.amerigroup.com/MD > Provider Resources & Documents > Manuals & QRCs > HealthChoice Provider Manual).

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Review of information on file for your practice

To better communicate with providers and improve member access to providers, Amerigroup Community Care maintains an up-to-date, accurate and complete provider directory. Please take a moment to review the information we have on file for your practice. If information is incorrect or outdated, please update your practice profile.

You will be able to review and update the following information: � Office details (e.g., address, billing address or office hours) � Provider location details � Provider details (e.g., provider specialty or accepting new patients) � Cultural Competency Training participation � Web address � Americans with Disabilities Act compliance

Review your directory profile information

You will be able to sign in and access your practice profile using your TIN. Once signed in, you will be able to review your practice’s profile information and make any necessary changes or updates.

What if I need assistance?If you have any questions about this initiative, please contact your local Provider Relations representative or call our Provider Services team at 1-800-454-3730. If you have problems accessing the website above or entering information, email AmerigroupMDDCproviderdata@morpace.com. Morpace, Inc. is an independent research firm that is helping us collect accurate information.

Thank you for your continued support in keeping provider records up to date and accurate for our members.MD-NL-0127-18

Wound care treatment request update

Effective September 1, 2018, Amerigroup Community Care will require all wound care requests to include current clinical documentation. This must include clear documentation of medical necessity of care including history, effectiveness of treatment and plan of care (POC).

Requests for wound care services supporting documentation may adversely affect the outcome of requested services.

Read the full provider update to learn more about the documentation required, the correct authorization form to use and what happens after your submit a request.MDPEC-1610-18

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The Interactive Care Reviewer tool is available — Start using today!

The Interactive Care Reviewer (ICR) tool offers a streamlined process to request authorization of inpatient and outpatient procedures as well as locate information on previously submitted requests for Amerigroup Community Care members via the Availity Portal.

What benefits does the ICR tool provide? � Free and easy to use � Access almost anywhere � Preauthorization determinations � Inquiry capability � Fax reduction � Ability to view decision letter � Ability to save favorites � Comprehensive view of all your preauthorization requests

How do I gain access to the ICR tool?You can access the ICR tool through Availity. (Select Authorizations & Referrals from the Patient Registration drop-down menu in the upper left of the page.)

If you have not yet registered for Availity, go to https://www.availity.com and select Register at the top of the page. Select your Organization Type from the available options at the bottom of the page and follow the registration wizard.

How can I learn more about ICR? Learn more about ICR by attending one of the monthly webinars.

Who can I contact with questions? For questions regarding our ICR tool, please contact your local Provider Network Relations representative or contact Provider Services at 1-800-454-3730.

For questions on accessing our tool via Availity, call Availity Client Services at 1-800-282-4548. Availity Client Services is available Monday-Friday from 8 a.m.-7 p.m. Eastern time (excluding holidays) to answer your questions.

Note: ICR is not currently available for requests involving transplant services or services administered by AIM Specialty Health® or OrthoNet LLC. For these requests, follow the same preauthorization process you use today.MD-NL-0122-18

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More than a score: working together to achieve better health outcomes while meeting HEDIS measures

We know you’ve heard of HEDIS®. We send you report cards, letters and reminders about members overdue for services related to HEDIS measures — You might even be eligible for incentive payments when helping members get these important services.

But it’s not just about the scores. It’s about the woman whose Pap smear led to early detection and treatment of her cervical cancer. It’s the toddler who didn’t get whooping cough during last year’s outbreak because he got his vaccine on time. Or the grandfather who kept up with cholesterol screenings and avoided another heart attack.

We thank you for giving our members the highest quality care possible. Working together to meet these benchmarks, we have the best chance of improving our members’ health outcomes and, ultimately, their quality of life.

Our benchmarks for clinical performance and service satisfaction � The Healthcare Effectiveness Data and Information Set (HEDIS) is a program developed

by the NCQA to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 80 measures across five domains of care.

� The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a survey evaluating member satisfaction with care and services received over the past six months by asking a random sample of plan members questions about their providers and the health plan.

� The Provider Satisfaction Survey is an annual survey to find out what you, our providers, think we’re doing well and what we can do better in several capacities, including communication and technology, claims processing, and customer service.

HEDIS, CAHPS and the Provider Satisfaction Survey results help us identify areas of strength and areas where we need to focus our improvement efforts. We use the results to:

� Assess the services and care our members are receiving. � Measure our performance against our goals. � Determine the effectiveness of actions we implemented to improve our results.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).MD-NL-0128-18

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Clinical Practice Guidelines notification

Clinical Practice Guidelines are evidence-based guidelines known to be effective in improving health outcomes. Guideline effectiveness is determined through scientific evidence, professional standards or expert opinion. Amerigroup Community Care provides clinical and preventive health guidelines to our network physicians. These guidelines are based on current research and national standards.

Members and providers may request a paper copy of a guideline by calling Provider Services at 1-800-454-3730. They are also available on our website at https://providers.amerigroup.com/MD.MD-NL-0129-18

Reminder from the Operations department regarding member appeals

When a provider is submitting an appeal on behalf of a member they must submit:

� A written/signed member consent to appeal on their behalf.

� The appeal letter. � Clinical information.

Per Maryland Department of Health Code of Maryland Regulations 10.09.71.05 and the Amerigroup Community Care Member Handbook, written/signed member consent to appeal on their behalf must be included with all preservice appeals submitted by a third party. You can find the Member Handbook by visiting https://www.myamerigroup.com/md > Benefits > Member Materials.MD-NL-0132-18

Members’ Rights and Responsibilities Statement

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to participating practitioners and members in our system, Amerigroup Community Care has adopted a Members’ Rights and Responsibilities Statement, which is located in your Provider Manual.

If you need a physical copy of the statement, call Provider Services at 1-800-454-3730.MD-NL-0134-18

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Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our Medical Policies are available on our provider website.

You can request a free copy of our UM criteria from Provider Services at 1-800-454-3730. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the number listed below. To access UM criteria online, go to https://providers.amerigroup.com/MD > Provider Resources & Documents > Quick Tools > Medical Policies.

We are staffed with clinical professionals who coordinate our members’ care and are available 24 hours a day, 7 days a week to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by: � Faxing to 1-800-964-3627. � Calling us at 1-800-454-3730. � The Availity Portal at https://www.availity.com.

Have questions about utilization decisions or the UM process?Call our Clinical team at 410-981-4050 Monday-Friday from 8:30-5:30 p.m. Eastern time.MD-NL-0134-18

Electronic Data Interchange migration to Availity

Recently, Amerigroup Community Care partnered with Availity as our designated Electronic Data Interchange (EDI) gateway and E-Solutions Service Desk, and Amerigroup will not renew existing contracts with clearinghouse vendors. As a result, beginning January 1, 2019, Availity will manage all EDI trading partner relationships on behalf of Amerigroup. This new partnership will not interrupt your current services.

Transmitting 837 claimsIf you currently transmit 837 claims using a clearinghouse, you should contact your clearinghouse as soon as possible to confirm your EDI submission path for Amerigroup transactions has not changed. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Direct submitters can also use Availity for their 837 transmissions.

Registering with AvailityIf you choose to submit directly through Availity but are not yet a registered user, go to https://www.availity.com and select REGISTER. The registration wizard will lead you through the enrollment process. Once complete, you will receive an email with your login credentials and next steps for getting started. If you have any questions or concerns, please contact Availity at 1-800-AVAILITY (1 800-282-4548).

It is our priority to deliver a smooth transition to Availity for our EDI services. If you have questions, please contact your Provider Relations representative or Provider Services at 1-800-454-3730.MDPEC-1597-18

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Medical Policies and Clinical Utilization Management Guidelines updates

The Medical Policies and Clinical Utilization Management (UM) Guidelines detailed in the bimonthly update were developed 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.

Please share this notice with other members of your practice and office staff.

To search for specific policies or guidelines, visit https://medicalpolicies.amerigroup.com/search.

Medical PoliciesOn January 25, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup Community Care.

Please note: � Starting July 1, 2018, AIM Specialty Health®

Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.

Clinical UM Guidelines On January 25, 2018, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. The update details the guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

View the list of newly approved Medical Policies and Clinical UM Guidelines in the January 2018 update.MDPEC-1567-18

Medical PoliciesOn March 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup Community Care.

Clinical UM Guidelines On March 22, 2018, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. The update details the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

View the list of newly approved Medical Policies and Clinical UM Guidelines in the March 2018 update.MDPEC-1593-18

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Obstetric imaging precertification clarification

As previously communicated, as of June 1, 2018, Amerigroup Community Care now requires obstetric imaging services (CPT codes 76801-76817) for pregnant members who are not considered high risk to be performed in a free-standing facility. All obstetric imaging services performed in the outpatient hospital facility-based setting will require precertification.

A standard examination to provide a general anatomic fetal survey is adequate for most pregnancies. This type of exam will establish or confirm due dates, evaluate fetal presentation, amniotic fluid volume, heart activity, placental position and number of fetuses, and screen for gross anatomic abnormalities (abdomen, chest, extremities, head, face, neck, sex and spine).

The American College of Obstetricians and Gynecologists recommends that in the absence of specific indications, the optimal time for an obstetric ultrasound examination is between 18-20 weeks of gestation because anatomically complex organs, such as the fetal heart and brain, can be imaged with sufficient clarity to allow detection of many major malformations.

Outpatient hospital facility-based obstetric imaging is medically necessary for pregnant members who are considered high risk and are being treated by a perinatologist for any of the following:

Advanced maternal age

� Any woman over the age of 35 is considered advanced maternal age. � Genetic concerns are more common in this population of women (Down syndrome,

extra copy of chromosome 21).

High blood pressure (HBP)

� Uncontrolled HBP can cause decreased blood flow and oxygen through the placenta to the fetus, placenta abruption, intrauterine growth restriction, maternal organ damage, premature delivery or future cardiovascular disease.

Increased blood glucose

� Uncontrolled elevated blood sugar increases the risk for congenital heart defects. � Larger babies have an increased risk for unstable blood glucose maintenance. � This can increase the risk of miscarriage, preterm delivery, growth restriction, and

complications for both mom and baby.

Multiple gestation

� Monitoring growing fetuses and their development is vital due to the increased risk of preterm delivery, lower weight babies and possible twin-to-twin transfusion.

� Any member with a current diagnosis of a mental health disorder taking any psychotropic medications, mood stabilizers, benzodiazepines, narcotics and all forms of antidepressants are at higher risk of complications.

When submitting a precertification request, the following parameters apply:1. No consultation is needed with Maternal and Fetal Medicine prior to the ultrasound.2. The provider must state why the member is being referred to a perinatologist.3. The provider must submit the gestational age and documentation to support the high-risk diagnosis.4. If multiple visits are required, providers don’t need to submit another precertification request once approved. 5. The provider must submit a precertification request for nuchal translucency ultrasound in the city and all

counties, but Amerigroup will approve the request in the city setting if high risk is documented.

Use one of the following methods to request precertification: � Phone: 1-800-454-3730 � Fax: 1-800-964-3627 � Web: https://www.availity.com

MD-NL-0130-18

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New HealthChoice Benefit Requirement Audiology Services for Children and Adults(Effective July 1, 2018)

OverviewEffective July 1, 2018, HealthChoice MCOs will be responsible for covering medically necessary audiology services, hearing aids, cochlear implants, and auditory osseointegrated devices for all managed care enrollees regardless of age. Currently, audiology coverage is limited to participants under the age of 21 and provided through the EPSDT Program.

Coverage requirementsCoverage details—including the Department’s new benefit package, preauthorization requirements, and fee schedule for Audiology Services—are attached.

Licensure requirementsTo begin providing services, MCOs must enroll audiologists into their provider networks. Audiologists are required to be licensed by the Maryland Board of Audiologists, Hearing Aid Dispensers, and Speech-Language Pathologists to practice audiology or by the appropriate licensing body in the jurisdiction where the audiology services are performed.

Fee schedule MCOs will not be required to use the Department’s updated fee schedule for Audiology Services. Under FFS, the fee schedule will not differ for children and adults. We expect our fee schedule’s rates to attract audiology providers. However, your MCO may choose to pay providers less if you are able to provide adequate access to care.

Medical necessity criteriaThe Department shared medical necessity criteria with MCO Medical Directors on Wednesday April 11, 2018. Medical necessity criteria for children and adults will differ in the new coverage package. Benefits for children will be more liberal than for adults. For example, children will be eligible for coverage of unilateral or bilateral hearing aids at any degree of hearing loss. Adults with moderate hearing loss will be eligible for initial coverage of unilateral aids with bilateral aids only covered when certain criteria are met. The Department expects the MCO’s benefit criteria to be similar to what is detailed in our FFS benefit package.

Prior authorizationMCOs are not required to use the Department’s preauthorization requirements, but we assume that MCOs will preauthorize hearing aids, cochlear implants, and auditory osseointegrated devices. The attached fee schedule identifies which procedure codes will require preauthorization in the FFS program. Our preauthorization requirements will be the same for children and adults.

Self referral servicesMCOs are not required to use the FFS preauthorization requirements. In Medicaid FFS, the Program will expect the patient to be referred to an audiologist by a physicianMD-NL-0137-18

A message from the Maryland Department of Health:

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Behavioral Health (BH) Corner

Welcome to the BH Corner, in collaboration with Beacon Health Options (Beacon). The BH Corner includes updates on topics that impact all providers, no matter what specialty or service they provide. In addition, Beacon will provide brief updates to changes within the Maryland Public Behavioral Health System.

Adolescent suicidality in medical and primary care settingsSuicide rates for adolescents have been rising since 2007. Suicide rates for girls ages 15-19 have doubled from 2007-2017. During that same timespan, the suicide rate for boys ages 15-19 rose by 50%. Office-based physicians are often faced with the dilemma of making a judgment call on the seriousness of suicidality presented by an adolescent in their exam room. How does one screen and make clinical decisions regarding the safety of an individual child or adolescent?

A simple, easy-to-use screening tool is the Ask Suicide-Screening Questions (ASQ), designed to be used in medical settings. The ASQ employs a three-stage strategy to help clinicians assess risk and make decisions on disposition. Five questions determine whether the individual is a negative screen, a nonacute positive screen or an acute positive screen. Any adolescent screening positive requires a brief suicide safety assessment to determine if a full mental health evaluation is necessary. An acute positive screen requires an immediate safety screen/full mental health evaluation. The ASQ can be found on the National Institutes of Health site.

Recent updates in the Maryland Public Behavioral Health System

� Beacon now manages adult residential treatment services for substance use disorders (SUDs). For information on these services or how to refer your patients for SUD assessments, please contact Beacon at 1-800-888-1965.

� Medication Assisted Treatment (including buprenorphine and Vivitrol) for SUD is now available in multiple treatment settings in addition to traditional opioid treatment programs.

� The state expanded services in January 2018 for the treatment of gambling disorders delivered by SUD treatment programs.

� As of January 2018, Maryland Medicaid no longer reimburses laboratories for definitive urine drug screens greater than 14 substances. The Maryland Department of Health (MDH) recommends providers use the American Society of Addiction Medicine Smart Testing guidelines. The MDH also added coverage for providers who have appropriate equipment to perform more extensive presumptive drug testing in their office. Please contact Beacon for questions associated with covered drug testing changes.

� For pregnant patients with substance use or mental health disorders requiring collaboration and coordination of behavioral health and medical care, contact Jay Hensley at Beacon: jay.hensley@beaconhealthoptions.com.

� As of January 1, 2018, Medicaid covers applied behavioral analysis (ABA) for children with autism spectrum disorder. Contact ABAMarylandproviderrelations@beaconhealthoptions.com for information or referrals.

For help with referrals to a mental health or SUD treatment provider, call Beacon at 1-800-888-1965. For additional information on screening tools and other topics, visit our website. Select the tab for Non Behavioral Health Provider.

If there are topics you would like to see in future editions of the Behavioral Health Corner, please email lynn.taylor@beaconhealthoptions.com.

Amerigroup works with Beacon to provide mental health services to our members.

MD-NL-0131-18

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Prior authorization requirements

Mepolizumab (Nucala) and reslizumab (Cinqair)

Effective September 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drugs mepolizumab (Nucala®) and reslizumab (Cinqair®).

PA requirements will be added to the following: � Mepolizumab (Nucala) — injection, 1 mg (J2182) � Reslizumab (Cinqair) — injection, 1 mg (J2786)

MD-NL-0121-18

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 and noncontracted providers on our provider website (https://providers.amerigroup.com/MD > Quick Tools > Precertification Lookup Tool). Providers may also call us at 1-800-454-3730 for PA requirements.

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Reimbursement Policy

Policy UpdateMedical Recalls(Policy 06-111 — effective 11/01/2018)

In applicable circumstances, the appropriate modifier, condition code or value code (identified below) should be used to identify a medically recalled item. This will assist Amerigroup Community Care in identifying medically recalled items and support correct coding guidelines.

Applicable condition codes are 49 and 50. Condition code 49 signifies products replaced within the product lifecycle due to the product not functioning properly, and condition code 50 is used for product replacement for known recall of a product.

When a credit or cost reduction is received by the provider for the replacement device, applicable modifiers are FB and FC. Modifier FB is used when items are provided without cost to the provider, supplier or practitioner, and modifier FC is used when a partial credit is received by the provider, supplier or practitioner for the replacement device.

Note: In circumstances where we have reimbursed the provider for repair or replacement of items or procedures related to items due to a medical recall, we are entitled to recoup or recover fees from the manufacturer and/or distributor as applicable. In circumstances where we have reimbursed the provider the full or partial cost of a replaced device and the provider received a full or partial credit for the device, we are entitled to recoup or recover fees from the provider.

Please refer to CMS and/or your state’s guidelines, and the Medical Recalls reimbursement policy for additional details at https://providers.amerigroup.com/MD > Quick Tools > Reimbursement Policies > Medicaid/Medicare.MD-NL-0104-18