https://provider.amerigroup.com/��Provider Services: Medicaid: 800-454-3730 | Medicare: 866-805-4589

Provider NewsBlast

TN-NB-0473-21-B

June 2021

Medicaid: Page 2Important information about utilization management Page 2

What Matters Most: Improving the Patient Experience Page 3

Coding spotlight: mental disorders in childhood Page 3

Keeping up with routine vaccinations during COVID-19 Page 3

MCG Care Guidelines 25th edition Page 4

Medical drug benefit Clinical Criteria updates Page 4

Updates to the AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Page 4

Hysterectomy Page 5

Sterilizations

IUD insertion codes Page 5

Elective abortions Page 5

Complex Case Management program Page 6

Correction to a step therapy update Page 6

Members’ Rights and Responsibilities Statement Page 6

Medicare Advantage: Page 7Updates to the AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Page 7

MCG Care Guidelines 25th edition Page 7

Medical drug benefit Clinical Criteria updates Page 7

Amerigroup Community Care working with Optum to collect medical records for risk adjustment

Page 8

Table of Contents

Reimbursement Policies: Page 12Inpatient Readmissions Page 12

COVID-19 information from Amerigroup Community Care Page 2

Long-Term Services and Supports (LTSS): Page 9

Person-centered integration of I/DD programs and services Page 9

Reinstatement of timely filing and claims submission for Employment and Community First CHOICES

Page 9

Service spotlight Page 10

Provider demographic reminder Page 11

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Amerigroup Community Care complies with the applicable federal and state civil rights laws, rules, and regulations and does not discriminate against members or participants in the provision of services on the basis of race, color, national origin, religion, sex, age, or disability. If a member or a participant needs language, communication, or disability assistance or to report a discrimination complaint, call 800-454-3730. Information about the civil rights laws can be found online.

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Medicaid

COVID-19 information from Amerigroup Community Care

Amerigroup Community Care is closely monitoring COVID-19 developments and how it will impact our customers and provider partners. Our clinical teams are actively monitoring external queries and reports from the Centers for Disease Control and Prevention (CDC) and Tennessee Department of Health to help us determine what action is necessary on our part.

For additional information, reference the COVID-19 section of our website.TNPEC-3531-20-A

Important information about utilization management

Our utilization management (UM) decisions are based on established medical necessity criteria, 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 800-454-3730. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the number listed below. You can access the UM criteria online.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 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 via: � Fax at 800-964-3627. � Phone at 800-454-3730. � The Availity Portal.*

Have questions about utilization decisions or the UM process?Call our Clinical team at 800-454-3730 Monday through Friday from 8 a.m. to 5 p.m. CT.* Availity, LLC is an independent company providing administrative support services on behalf of Amerigroup Community Care.TN-NB-0463-21

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Coding spotlight: mental disorders in childhood

Mental disorders among children may cause serious changes in the way children typically learn, behave or handle their emotions, which cause distress and problems getting through the day. Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), to help diagnose mental health disorders in children.

Read more online.

TN-NB-0446-21

Keeping up with routine vaccinations during COVID-19

In May 2020, the CDC released a report showing a drop in routine childhood vaccinations as a result of COVID-19, a result of stay-at-home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.

Read more online.

TN-NB-0449-21

What Matters Most: Improving the Patient Experience

What Matters Most: Improving the Patient Experience is an online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

You can access the What Matters Most course online.TN-NB-0452-21

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Medical drug benefit Clinical Criteria updates

On February 19, 2021, and March 4, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Amerigroup Community Care. These policies were developed, revised or reviewed to support clinical coding edits.

TN-NB-0456-21

Updates to the AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Specialty Health®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe and affordable healthcare services.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Amerigroup Community Care.TN-NB-0440-21

Read more online.

Read more online.

MCG Care Guidelines 25th edition

Effective September 1, 2021, Amerigroup Community Care will upgrade to the 25th edition of MCG* Care Guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

* MCG Health is an independent company providing care guidelines on behalf of Amerigroup Community Care.TN-NB-0441-21

Read more online.

Page 5 of 12

Hysterectomy

Effective immediately, Amerigroup Community Care providers will be required to submit medical records in addition to a compliant Hysterectomy Acknowledgement Form for hysterectomies.

Requirements for filing a hysterectomy claim is as follows:

� The Hysterectomy Acknowledgement Form must be correctly completed and attached to the claim form.

� Physician must sign the Hysterectomy Acknowledgement Form after the procedure is performed when completing Section C.

� Documentation required: � A detailed history and physical and/or office

notes to include conservative measures tried prior to procedure, operative report, pathology report, correctly completed consent form.

As a reminder, you can find the Hysterectomy Acknowledgement Form on the Division of TennCare’s website.

SterilizationsReminder: Please refer to the TennCare website for updates on the Sterilization Consent Form instructions and FAQ. Any changes are effective July 1, 2021.TN-NB-0444-21

Elective abortions

Per our provider manual, medical records are required for elective abortion procedures.

Requirements for elective abortions: � Submit medical records to show mother’s life

was in danger or note in medical record that indicates incest or rape.

� If the above criteria are not found, claim will be denied.

� Having only a compliant abortion form will no longer be accepted as only documentation for paying the claim.

TN-NB-0445-21IUD insertion codes

As a reminder, providers must bill the intrauterine device (IUD), with the appropriate J code and NDC code, at zero dollars when they submit their claim for the IUD insertion code 58300. The device and the insertion charges must be on the same claim.TN-NB-0467-21

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Complex Case Management program

Managing illness can be a daunting task for our members. It is not always easy to understand test results, know how to obtain essential resources for treatment, or know whom to contact with questions and concerns.

Amerigroup Community Care is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals there to support members, families, PCPs, and caregivers. The complex case management process uses the experience and expertise of the Case Management team to educate and empower our members by increasing self-management skills. The complex case management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare.

Members or caregivers can refer themselves or family members by calling the Customer Service number located on their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.TN-NB-0462-21

Correction to a step therapy update

In a recent notification, we shared that effective May 1, 2021, the following codes would be included in our step therapy review process. Please be advised that these codes will NOT be included in our step therapy review process at this time.

Clinical Criteria HCPCS or CPT® codes DrugING-CC-0182 J1756 VenoferING-CC-0182 J2916 FerrlecitING-CC-0182 J1750 InfedING-CC-0182 J1439 InjectaferING-CC-0182 Q0138 FerahemeING-CC-0182 J1437 Monoferric

TN-NB-0459-21

Members’ Rights and Responsibilities Statement

The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare 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 within the provider manual. If you need a physical copy of the statement, call Provider Services at 800-454-3730.TN-NB-0466-21

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Coverage provided by Amerigroup Inc.

Medicare Advantage

Updates to the AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Specialty Health®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe and affordable healthcare services.

Read more online.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Amerigroup Community Care.TN-NB-0440-21/AGPCRNL-0177-21

MCG Care Guidelines 25th edition

Effective September 1, 2021, Amerigroup Community Care will upgrade to the 25th edition of MCG* Care Guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

* MCG Health is an independent company providing care guidelines on behalf of Amerigroup Community Care.TN-NB-0441-21/AGPCRNL-0180-21

Read more online.

Medical drug benefit Clinical Criteria updates

On February 19, 2021, and March 4, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Amerigroup Community Care. These policies were developed, revised or reviewed to support clinical coding edits.

TN-NB-0456-21/AGPCRNL-0184-21

Read more online.

Page 8 of 12

Amerigroup Community Care working with Optum to collect medical records for risk adjustment

In 2021, Amerigroup is collaborating with Optum,* which works with Ciox Health* (Ciox), to request medical records with dates of service for the calendar target year 2020 through present day. If you receive a request for medical records, it is because we have received a claim from you for a Medicare Advantage member during the time frame requested.

Read more online.

* Optum and Ciox Health are independent companies that provide medical record retrieval services on behalf of Amerigroup Community Care.AGPCRNL-0183-21

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Long-Term Services and Supports (LTSS)

Reinstatement of timely filing and claims submission for Employment and Community First CHOICES

Upon implementation of the Employment and Community First CHOICES (ECF CHOICES) program in 2017, timely filing was waived to allow providers time to become familiar with the new program and services offered. On January 12, 2021, the Division of TennCare notified the MCOs, who in turn notified providers, of the reinstatement of timely filing and claims submissions for services provided in the ECF CHOICES program. ECF CHOICES providers are required to comply with all timely filing requirements by July 1, 2021. If you have any outstanding claims questions, please reach out to your Provider Experience manager.

Visit our provider website to review the memo sent out by the Division of TennCare.TN-NB-0469-21

Person-centered integration of I/DD programs and services

The Division of TennCare announced the implementation of the person-centered integration of intellectual and developmental disabilities (I/DD) programs and services will be effective on September 1, 2021.

The Department of Intellectual and Developmental Disabilities (DIDD) and the Division of TennCare announced a plan to integrate and align all Medicaid long-term services and supports programs for people with I/DD. These programs include the Employment and Community First CHOICES program, the Section 1915c home and community based services waivers, and intermediate care facilities for individuals with intellectual disabilities. For the first time, all programs will be under the direct operational leadership, management, and oversight of DIDD. Find additional information regarding the I/DD integration online.TN-NB-0469-21

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Group 8Group 8 offers intensive behavioral community transition and stabilization services (IBCTSS) to members who fall into one of the following two categories:

� Member is diagnosed with intellectual or developmental disabilities (I/DD), at least 21 years of age, not living with family or transitioning out of a family, residing in a setting with a higher intensity level of care, or in incarceration. Additionally, the member must be diagnosed with a behavioral or psychiatric diagnosis that places themselves or others at an elevated risk of harm.

� Member is diagnosed with I/DD, 18 to 21 years of age and aging out of state custody, is not living with family or transitioning out of a family environment, resides in a setting with a higher intensity level of care, or in incarceration. Additionally, the member must be diagnosed with a behavioral or psychiatric diagnosis that places themselves or others at an elevated risk of harm.

This level of support was designed to be time limited, and those enrolled receive the benefits listed in the Group 7 section. In addition, members supported in Group 8 will have access to a variety of other benefits, including psychiatric care, 24/7 specially trained staff support, individual education and training, and access to peer-to-peer planning, rooted in a person-centered approach.

How do I join this network?If you would like more information or would like to speak with someone about joining our Group 7 and 8 network, please contact your Provider Experience manager. Together, we can uplift our communities!TN-NB-0469-21

Amerigroup Community Care proudly supports people receiving services in Employment and Community First CHOICES Groups 7 and 8. It is our hope that collaborating with providers to offer this type of support to members who qualify for these groups will be beneficial to both the provider and the member. Amerigroup would like to offer a glimpse of the Group 7 and 8 services as you are investigating the possibility of incorporating these services into your organization.

Group 7Group 7 offers intensive behavioral family-centered treatment, stabilization, and supports (IBFCTSS). This entails family-centered services with integrated behavioral health and home- and community-based supports. IBFCTSS provides support for members up to 21 years old and who are living with family.

Service spotlight

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Provider demographic reminder

To ensure all provider records are kept up to date with correct demographic information, please remember to update any changes to your address.

For an address change, submit requests on letterhead (even if marked on annual recredentialing application) and send to your Provider Experience manager noting the following within the document:

� Name of provider or group � Tax ID and NPI number � Old location, telephone, and fax � New location, telephone, and fax

� Note if this new location is the primary location or an additional location

� Effective date of address change

Please note: All operating facility changes tied to a license must go through credentialing with full credentialing packets and updated credentialing documents, such as a W-9, Certificate of Insurance (COI), and licensure. Timely submission of address changes are important to maintain record accuracy. Please send notification requests as soon as your organization is made aware of the change. If you have any questions regarding this process, please reach out to your assigned Provider Experience manager.TN-NB-0469-21

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Reimbursement Policies

Policy Reminder — Medicare AdvantageInpatient Readmissions

As a reminder, Amerigroup Community Care does not allow separate reimbursement for claims that have been identified as a readmission to the same hospital for the same, similar or related condition unless provider, federal or CMS contracts and/or requirements indicate otherwise, as further described in the existing reimbursement policy, available online.

If Amerigroup determines that this reimbursement policy has not been followed, Amerigroup may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Amerigroup and Amerigroup policies.

For more detailed information on the Inpatient Readmissions reimbursement policy, please visit our provider website.AGPCARE-0936-21