SM December 2014 - AmeriHealth · Billing Professional ... 2015 Medical and claim payment policy activity posted October 25 – November 20, 2014 ... Beginning in early 2015, we will

updateSM

ICD-10: External testing with providers will resume in 2015 page 4

Prescription drug updates page 19

NaviNet® changes scheduled for December 2014 and early 2015 page 8

December 2014

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2014 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 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of AmeriHealth HMO, Inc. and its affiliates (AmeriHealth) created to provide valuable information to the AmeriHealth-participating provider community. 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]

Inside this edition

AmeriHealth HMO, Inc. and AmeriHealth 65® NJ HMO have an accreditation status of Commendable from the National Committee for Quality Assurance (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

Announcements ► AmeriHealth New Jersey introduces Community Advantage,

adding two South Jersey hospitals

ICD-10 ► ICD-10: External testing with providers will resume in 2015

Administrative ► Changes to Medicare Advantage Addendum effective January 1, 2015 ● Options available for your capitated outpatient laboratory provider ● Reminder: Check member eligibility at every visit ● Stay informed during our transition to a new platform ► How to initiate an AmeriHealth New Jersey provider appeal

for commercial members ► Referring members for laboratory services

NaviNet®

► NaviNet® changes scheduled for December 2014 and early 2015

Billing ► Professional Injectable and Vaccine Fee Schedule updates

effective January 1, 2015 ► Transitioning outstanding Accounts Receivable balances to

new platform

Medical ► Upcoming policy on transcutaneous electrical nerve stimulators

and associated supplies ► Presumptive and definitive drug testing ● Reminder: Precertification requirements for DME providers go into

effect January 1, 2015 ● Reminder: Precertification requirement for non-emergent outpatient

radiation therapy starts January 1, 2015 ► Medical and claim payment policy activity posted October 25 –

November 20, 2014 ● Reminder: Upcoming changes to precertification requirements for

medical benefit drugs

Products ► AmeriHealth Medigap, our new Medicare supplement product

Pharmacy ► Important information on prescribed narcotic therapy ► Select Drug Program® Formulary updates ► Compounded medication policy update ► Prescription drug updates ► Nasonex® to be removed from Select Drug Program® Formulary

Quality Management ● Standards for medical record documentation ► 2014-2015 Member Wellness Guidelines now available ● The AmeriHealth Quality Management Program promotes quality of

care and service ► 2014-2015 Clinical Practice Guideline Summary now available ● Highlighting HEDIS®: Follow-up care for children prescribed

ADHD medication

December 2014 | Partners in Health UpdateSM 3 www.amerihealth.com

ANNOUNCEMENTS

AmeriHealth New Jersey introduces Community Advantage, adding two South Jersey hospitals AmeriHealth New Jersey, along with Cooper University Health Care, Shore Medical Center, and Cape Regional Medical Center, are working together to offer affordable, high-quality health care coverage. AmeriHealth New Jersey has expanded its relationship with these local hospitals in order to help transform the delivery of health care in New Jersey.

In 2014, we introduced a new tiered product called Cooper Advantage. For 2015, this product will have a new name – Community Advantage. Cape Regional Medical Center and Shore Medical Center, along with their more than 400 physicians, will be added to Community Advantage as Tier 1 providers.

Our Community Advantage plans are tailored to meet the needs of individuals and employers based in the following counties:

● Atlantic ● Cape May ● Burlington ● Gloucester ● Camden

Members may choose a Community Advantage plan during the 2015 open enrollment period, which began November 15, 2014. Individuals and families who purchase a Community Advantage product will have access to participating providers throughout the state via the Local Value Network; however, they will pay the lowest out-of-pocket costs when using Tier 1 providers (i.e., providers from Cooper University Health Care, Shore Medical Center, and Cape Regional Medical Center).

Goals and benefits of Community AdvantageCommunity Advantage aims to achieve three key goals:

● encourage collaboration and care coordination across the delivery systems among hospitals, specialists, and primary care physicians;

● promote clinical integration of hospitals and physicians;

● reward the delivery of high-quality and cost-effective care.

Key member benefits include: ● lowest out-of-pocket costs for members using Tier 1 providers;

● access to Tier 2 providers (i.e., larger, statewide Local Value Network) at higher out-of-pocket costs;

● incentive rewards through our Commit2Wellness® program. Commit2Wellness is designed to help members and their families stay well, prevent illness, and benefit from healthy lifestyle choices.

Learn moreAffected providers will receive a letter informing them of their Tier 1 placement, which will go into effect January 1, 2015.

If you have any questions, please call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241) or contact your Network Coordinator or Hospital/Ancillary Services Coordinator.

ICD-10


ADMINISTRATIVE

As previously communicated, the U.S. Department of Health and Human Services has confirmed in a final rule that October 1, 2015, will be the compliance deadline for the implementation of ICD-10. The final rule requires the continued use of ICD-9 through September 30, 2015.

External testingAmeriHealth is in the process of reassessing and communicating our external testing plan and schedule. Beginning in early 2015, we will resume external testing with our pre-established testing partners and share our successes and challenges with our provider network.

Learn moreDetailed information about external testing schedules will be communicated in future editions of Partners in Health Update and within the ICD-10 section of our website at www.amerihealth.com/icd10.

ICD-10: External testing with providers will resume in 2015

ICD-10Will you

be ready?

Changes to Medicare Advantage Addendum effective January 1, 2015Effective January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) will revise contractual regulations 42 CFR §§ 422.504(i)(2)(i) and 423.505(i)(2)(i) to make clear that CMS and its designees may “collect” records, in addition to their existing authority to “audit, evaluate, and inspect” information, from First-Tier, Downstream, and Other Related Entities (FDRs).

In accordance with these changes, the Medicare Advantage Addendum will be amended to read as follows:

Inspection and Audit. Contractor shall permit CMS, the Department of Health and Human Services (HHS), the Comptroller General, or their designees to audit, evaluate, collect, and inspect any books, contracts, computer, or other electronic systems, including medical records and documentation of the FDRs related to CMS’s contract with the Medicare Advantage organization as it pertains to any Services provided under the Agreement. CMS, HHS, the Comptroller General, or their designees have the right to audit, evaluate, collect, and inspect any records directly from any FDRs. This right to audit, evaluate, collect, and inspect shall extend ten (10) years from the expiration or termination of the Agreement or completion of final audit, whichever is later, unless otherwise required by applicable Law.

Please note, this is for informational purposes only and does not require any action on your part at this time. Updates to the Medicare Advantage Addendum will take place upon contract renewal.

ADMINISTRATIVE


Options available for your capitated outpatient laboratory providerThere are several options available to AmeriHealth primary care physicians (PCP) when choosing a participating capitated outpatient laboratory provider, including, but not limited to, the following:

● Laboratory Corporation of America (LabCorp®) ● Quest Diagnostics®

● Bio Reference Laboratory (New Jersey only)

As a reminder, PCPs in our network are required to select a participating capitated laboratory provider. HMO/POS members should use their PCP’s capitated laboratory provider when in need of lab services.* HMO/POS members’ ID cards show the Lab Indicator of their PCP’s capitated laboratory provider, as shown in the sample ID card.

Keep in mind the following: ● To obtain current capitation information, use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal.

● PCPs may obtain a specimen in the office or send an HMO member to a drawing station. ● Specialists (including OB/GYNs) must send HMO member specimens to the laboratory capitated by that member’s PCP. Whether specialists obtain the specimen in their office or direct the member to a draw site operated by one of the capitated laboratories for testing, the study must be performed by the laboratory capitated by the member’s PCP.

● All members sent to a drawing station must be sent with the appropriate laboratory requisition form. ● The requesting office should complete the appropriate laboratory requisition form (not an HMO referral). These requisition forms permit multiple physicians to receive results; the initiator must provide full names and addresses of the physicians who should receive a duplicate copy. Note: If the member does not present the requisition form when his or her blood is drawn, the member will be billed by the drawing station.

To locate drawing stations for a participating outpatient laboratory, go to www.amerihealth.com/find_a_provider, select Find Participating Doctors, Hospitals, and Ancillary Providers, and choose Laboratories from the “Search by provider type” drop-down menu.

*AmeriHealth New Jersey members may choose to receive routine laboratory services authorized by their PCP from a participating outpatient laboratory provider other than their PCP’s capitated laboratory provider. However, please note that this requires the member to have a referral issued by their PCP. Refer to the Provider Manual for Participating Professional Providers for more information.

Reminder: Check member eligibility at every visitThere are occasions when a member’s health insurance may be effective before his or her ID card is received in the mail. In this situation, you can still verify the member’s eligibility by using the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal and selecting the “Patient Name/Patient Date of Birth” search type. Members can also print a temporary ID card by logging on to our secure member portal at www.amerihealthexpress.com.

For eligibility inquiries, providers in New Jersey may call 1-888-YOUR-AH1 (1-888-968-7241).

ADMINISTRATIVE


Stay informed during our transition to a new platformAs you may know, AmeriHealth is in the process of transitioning its membership to a new operating platform. Our migration of AmeriHealth Pennsylvania commercial members is in progress, and we will migrate all AmeriHealth New Jersey Medicare Advantage HMO members to the new platform on January 1, 2015. Additionally, AmeriHealth New Jersey commercial members will be migrated to the new platform by October 1, 2015.

During the migration, we are working with you in a dual claims-processing environment. In other words, we are processing a larger portion of claims and business transactions on the new platform as members are migrated, and we continue to process claims and conduct business transactions on the current platform for members who have not yet been migrated.* The date of service will determine the platform on which claims are processed.

We are committed to working closely with our entire provider network as we complete this transition. We will continue to provide comprehensive communications and resources to support our members and provider network, both during and after the transition to the new platform.

Be sure to visit our System and Process Changes site at www.amerihealth.com/pnc/changes. On this site you will find several resources, including a communication archive and frequently asked questions. If you still have questions after reviewing these resources, email us at [email protected].

*Behavioral health claims for HMO/POS non-migrated members should continue to be submitted to Magellan Behavioral Health, Inc. Behavioral health claims for all migrated members, including HMO/POS, should be submitted to AmeriHealth.

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

How to initiate an AmeriHealth New Jersey provider appeal for commercial membersIn accordance with the provisions of Health Claims Authorization, Processing, and Payment Act (HCAPPA), a health care provider may initiate a first-level provider appeal. For AmeriHealth New Jersey commercial members, the appeal must be received on or before the 90th calendar day following the receipt of our claims determination. Submit your appeal request using the Health Care Provider Application to Appeal a Claims Determination form, as specified by the New Jersey Department of Banking and Insurance (DOBI).

Along with the DOBI form, the provider should submit any additional relevant information in support of the appeal.

A copy of this form is available on our website at www.amerihealth.com/pdfs/providers/interactive_tools/forms/appeals_claim_form.pdf. Please send the claim form and any supporting documentation to:

AmeriHealth New Jersey Provider Claim Appeals Unit259 Prospect Plains RoadBuilding MCranbury, NJ 08512

You may also email the form to [email protected] or fax the form to 609-662-2480.

Please contact your Network Coordinator or Hospital/Ancillary Services Coordinator with any questions.

© 2014 AmeriHealth | 18071 | 2014 July

AmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.

1

Submit to:AmeriHealth New JerseyProvider Claim Appeals Unit259 Prospect Plains Road, Bldg. M Cranbury, NJ 08512Fax to: 609-662-2480

New Jersey Departmentof Banking and Insurance

You have the right to appeal Amerihealth New Jersey’s1 claims determination(s) on claims you submitted to us. You also have the right to

appeal an apparent lack of activity on a claim you submitted.

DO NOT submit a Health Care Provider Application to Appeal a Claims Determination IF:

Our determination indicates that we concluded the health care services for which the claim was submitted were

not medically necessary, were experimental or investigational, were cosmetic rather than medically necessary or

dental rather than medical. INSTEAD, you may submit a request for a Stage 1 UM Appeal Review to appeal such

determinations. For more information, contact 877-585-5731 (Please select Prompt #2).

Our determination indicates that we considered the person to whom health care services for which the claim was

submitted to be ineligible for coverage because the health care services are not covered under the terms of the

relevant health benefi ts plan, or because the person is not our member. INSTEAD, you may submit a complaint.

For more information, contact 1-888-YOUR-AH1 (1-888-968-7241).

We have provided you with notice that we are investigating this claim (and related ones, as appropriate) for

possible fraud.You MAY submit a Health Care Provider Application to Appeal a Claims Determination IF Our determination:

Resulted in the claim not being paid at all for reasons other than a UM determination or a determination of

ineligibility, coordination of benefi ts or fraud investigation

Resulted in the claim being paid at a rate you did not expect based upon the contract between you and us, if any,

or the terms of the health benefi t plan.Resulted in the claim being paid at a rate you did not expect because of differences in our treatment of the codes

in the claim from what you believe is appropriate

Indicated that we require additional substantiating documentation to support the claim and you believe that the

required information is inconsistent with our stated claims handling policies and procedures, or is not relevant to

the claim.You also MAY submit a Health Care Provider Application to Appeal a Claims Determination IF:

You believe we have failed to adjudicate the claim, or an uncontested portion of a claim, in a timely manner

consistent with law, and the terms of the contract between you and us, if any

Our determination indicates we will not pay because of lack of appropriate authorization, but you believe you

obtained appropriate authorization from us or another carrier for the services

You believe we have failed to appropriately pay interest on the claim

You believe our statement that we overpaid you on one or more claims is erroneous, or that the amount we

have calculated as overpaid is erroneousYou believe we have attempted to offset an inappropriate amount against a claim because of an effort to recoup

for an overpayment on prior claims (essentially, that we have under-priced the current claim)1 A carrier’s contractors (organized delivery systems and other vendors) are subject to the same standards as the carrier when performing claim payment and

claim processing functions (including overpayment requests) on behalf of the carrier. Use of the words We, Us or Our includes our relevant contractors.

Health Care Provider Application to Appeal a Claims Determination

www.amerihealth.com/pdfs/providers/interactive_tools/forms/appeals_claim_form.pdf

ADMINISTRATIVE


Referring members for laboratory servicesAs a reminder, AmeriHealth requires you to direct members and/or their lab specimens to a participating outpatient laboratory provider, with the following exceptions:

● in an emergency; ● as otherwise described in the applicable Benefit Program Requirements;

● as otherwise required by law.

Please note the following information specific to various types of benefits plans:

● For HMO/POS members.* All routine laboratory services for HMO/POS members must be referred to their primary care physician’s (PCP) capitated laboratory site. In the unusual circumstance that you require a specific test that you believe the PCP’s capitated laboratory site can’t perform, call Customer Service, as preapproval is required to issue a referral to a laboratory other than the member’s capitated laboratory.

● For PPO members. PPO members should use a participating laboratory, such as Laboratory Corporation of America® Holdings (LabCorp) or Quest Diagnostics®, to maximize their benefits and save on out-of-pocket costs. PPO members may use a nonparticipating laboratory, but they will pay the out-of-network level of cost-sharing (copayment, coinsurance, deductible) and will be subject to provider balance billing. In the unusual circumstance that specific services are not available through a participating laboratory, providers must call Customer Service to obtain preapproval.

Contractual obligation to use participating providersIn accordance with your AmeriHealth Provider Agreement, except in an emergency, a participating provider should refer members only to participating providers for covered services. This includes, but is not limited to, ancillary services such as laboratory and radiology, unless the provider has obtained preapproval from AmeriHealth for the use of a nonparticipating laboratory.

Noncompliance may result in financial and other implications for your practiceWhen applicable under the terms of your AmeriHealth Provider Agreement, if a provider continues to direct members and/or their lab specimens to a nonparticipating laboratory and does not obtain

preapproval from AmeriHealth, the ordering provider is required to hold the member harmless.

The ordering provider will be responsible for any and all costs to the member and shall reimburse the member for such costs or be subject to claims offset by AmeriHealth for such costs. In addition, further non-compliance may result in immediate termination of your AmeriHealth Provider Agreement.

Exception to the use of nonparticipating providers permitted under the terms of your agreementIf a provider (1) refers a member to a nonparticipating laboratory for non-emergent services without obtaining preapproval from AmeriHealth to do so; (2) sends a member’s lab specimen to a nonparticipating laboratory without preapproval; or (3) provides or orders non-covered services for a member, the provider must inform the member in advance, in writing, of the following:

● a list of the services to be provided; ● that AmeriHealth will not pay for or be liable for the listed services;

● that the member will be financially responsible for such services.

To access the Member Consent for Financial Responsibility Form, go to www.amerihealth.com/providerforms.

Providers should also be aware of the coverage status of the tests they order and should notify the member in advance if a service is considered experimental/investigational or is otherwise non-covered by AmeriHealth.

Note: Members who have out-of-network benefits (e.g., PPO) may choose to use a nonparticipating laboratory for a medically necessary service, but they may have greater out-of-pocket costs associated with that service. In addition, the member will be financially responsible for the entire cost of any service that is non-covered (e.g., experimental/investigational).

If you have any questions related to the referral process for laboratory services, please contact your Network Coordinator.

*AmeriHealth New Jersey members may choose to receive routine laboratory services authorized by their PCP from a participating outpatient laboratory provider other than their PCP’s capitated laboratory provider. However, please note that this requires the member to have a referral issued by their PCP. Refer to the Provider Manual for Participating Professional Providers for more information.

www.amerihealth.com/providerforms

NAVINET®


NaviNet® changes scheduled for December 2014 and early 2015This article details more changes to the NaviNet web portal that are scheduled for release in December 2014 and February 2015.

Coming in December 2014CareCore (for Pennsylvania members only)As previously communicated, for dates of service on or after January 1, 2015, precertification will be required for non-emergent outpatient radiation therapy for all commercial members in Pennsylvania. AmeriHealth is working with CareCore National, LLC (CareCore) to manage precertification requests for non-emergent outpatient radiation therapy services. Precertification is not required for radiation therapy in the inpatient hospital setting.

To initiate precertification for non-emergent outpatient radiation therapy, a new CareCore option will be added to the Authorizations menu in the list of plan transactions. This option will link to the CareCore provider portal, where providers can complete precertification requests.

Note: Providers will also be able to initiate precertification requests by calling CareCore directly at 1-866-686-2649. This precertification requirement does not apply to commercial or Medicare Advantage AmeriHealth New Jersey members.

Authorization submissionTo help expedite prior authorization requests, we will update several clinical questions related to specific chemotherapy/infusion services, medical/surgical procedures, home health, and durable medical equipment services.

Coming in February 2015NaviNet office conversionWe will be converting all NaviNet offices to the new platform in February as part of our ongoing transition to a new operating platform. Most providers will see a difference in their provider group drop-down menus within many individual transactions on NaviNet.

Some of the more significant changes that providers will see on the new platform include:

● consolidated drop-down lists, as there will no longer be a need for duplicate records to differentiate between HMO and PPO lines of business;

● elimination of customized provider group name descriptions.

Allowance Inquiry transactionThe new Allowance Inquiry transaction will be added as an option in the menu of plan transactions, replacing the retired Fee Schedule Inquiry transaction. This new transaction will return fees for professional providers only and will indicate where primary care physician capitation is generally applicable. The fees returned via Allowance Inquiry will be associated with migrated members only and will not include results for Traditional or Comprehensive Major Medical members.

Note: Provider payment allowance information will be for informational purposes only and will not be a guarantee of payment for the amount displayed.

Tiering information enhancementsWe will introduce enhancements in February that will assist providers when rendering services to members covered through one of our tiered products (e.g., Tier 1 Advantage, Community Advantage). The enhancements will allow providers to better identify appropriate member cost-sharing (e.g., copayment) and complete the referral and preapproval submission processes more easily for these members.

We will publish more information about these tiering information enhancements in future editions of Partners in Health Update.

For more informationTo help you better understand these changes, we encourage you to stay tuned to upcoming editions of Partners in Health Update and to review the NaviNet Transaction Changes section of our System and Process Changes site at www.amerihealth.com/pnc/changes.

If you have any questions about NaviNet updates, please call the eBusiness Hotline at 215-640-7410 for providers in Pennsylvania and Delaware and at 609-662-2565 for providers in New Jersey.

BILLING


Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2015 Effective January 1, 2015, we will implement a quarterly update to our Professional Injectable and Vaccine Fee Schedule for all contracted providers. These updates reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables.

If you have any questions about the updates or where to view them, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.

Transitioning outstanding Accounts Receivable balances to new platformSome practices and facilities have outstanding Accounts Receivable (A/R) balances on our legacy system where amounts are owed to AmeriHealth. As part of our transition to a new operating platform, we are in the process of identifying these practices and facilities and notifying these providers by mail.

If such outstanding A/R balances are identified, we will transition the A/R balance to the new operating platform, and the amount owed to AmeriHealth will be offset against any current or future claim payments to the practice or facility. The correspondence sent to affected providers will include a list of claims that account for the amounts owed to AmeriHealth.

Note: When the A/R is transitioned, the date of service and refund claim detail will no longer be available on the Provider Explanation of Benefits (professional providers) or Provider Remittance (facility providers) generated from the new platform. Therefore, it is important that affected providers keep a copy of the correspondence they receive.

If you have any questions about this process, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.

MEDICAL


Upcoming policy on transcutaneous electrical nerve stimulators and associated supplies Effective January 1, 2015, a new medical policy regarding transcutaneous electrical nerve stimulators (TENS) will outline medical necessity criteria and what is considered experimental/investigational.

About the TENS deviceA TENS is a nonpharmacologic and noninvasive treatment for symptomatic pain relief. The battery-operated device utilizes electrical current delivered through electrodes placed on the surface of the individual’s skin to decrease the perception of pain. It may be applied in a variety of settings such as the individual’s home, a professional provider’s office, or an outpatient clinic. If the medical necessity criteria are met, as outlined in the new policy, payment for TENS will be made under the benefits provided for durable medical equipment.

New policy detailsPlease note the following coverage position under the new policy:

● Acute post-operative pain. A TENS device is considered medically necessary for individuals with acute post-operative pain.

● Chronic pain – experimental/investigational. The use of a TENS device is considered experimental/investigational for the treatment of chronic pain (i.e., present for at least three months) when the presumed etiology of the pain is a type that is not accepted as responding to the TENS device, which includes the following: - visceral abdominal pain; - pelvic pain; - temporomandibular joint (TMJ) pain; - headache disorder pain (i.e., migraine,

tension-type headache, cluster headache and other trigeminal autonomic cephalgias, and other primary headaches);

- low back pain that is not a manifestation of a clearly defined and generally recognizable primary disease entity.Note: For Medicare Advantage HMO members, the Centers for Medicare & Medicaid Services will allow TENS coverage for chronic low back pain only when the individual is enrolled in an approved clinical study meeting specified requirements.

● Chronic pain – medically necessary. For the treatment of other types of chronic pain (i.e., present for at least three months), a 30 − 60 day trial of a TENS device is considered medically necessary when the presumed etiology of the pain is a type that is accepted as responding to TENS therapy and other appropriate treatment modalities (e.g., physical therapy, pharmacotherapy) have been tried and failed.

If a TENS device is effective in modulating pain after a 30 − 60 day trial rental period, the supplier can submit for purchase of the TENS unit and must provide documentation to support compliance and effective treatment. During the 30 − 60 day trial period, reimbursement for the TENS device will only be made as a rental. The rental cost of the TENS device is included in the purchase price of the TENS device.

All supplies (e.g., electrodes, lead wires, batteries) are included during the rental period and will not be reimbursed separately. Furthermore, replacement supplies, when used with a medically necessary TENS device, are considered medically necessary for the specified maximum utilization time frame as outlined in the policy.

For more informationTo review our position on Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies, refer to the Policy Notifications available at www.amerihealth.com/medpolicy after December 1, 2014. 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 Notification you’d like to view. Then type the policy name or number in the Search field:

● Commercial: #05.00.74: Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies;

● Medicare Advantage: #MA05.006: Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies.

You can also view policy activity through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

Please contact your Network Coordinator or Hospital/Ancillary Services Coordinator if you have any questions on the new TENS policy.

MEDICAL


Presumptive and definitive drug testing Effective January 1, 2015, AmeriHealth will implement a new medical policy related to coverage of both presumptive and definitive drug testing. Coverage for presumptive and definitive drug testing will be subject to specific medical necessity criteria and frequency limits identified in the medical policy.

To review our position on presumptive and definitive drug testing, refer to the Policy Notifications available at www.amerihealth.com/medpolicy after December 1, 2014. 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 Notification you’d like to view. Then type the policy name or number in the Search field:

● Commercial: #06.02.44: Presumptive and Definitive Drug Testing ● Medicare Advantage: #MA06.025: Presumptive and Definitive Drug Testing

You can also view policy activity through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

If you have any questions related to this new medical policy, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.

Reminder: Precertification requirements for DME providers go into effect January 1, 2015 Effective January 1, 2015, durable medical equipment (DME) providers will be required to obtain precertification for all APAP, BiPAP, and CPAP machines and replacement supplies (tubing, water chambers, face masks, etc.) for all commercial HMO and PPO and Medicare Advantage HMO members.

In the first quarter of 2015, enhancements will be made to the NaviNet® web portal to accommodate the submission of these requests through AIM Specialty Health® (AIM) using the AIM ProviderPortalSM. In the meantime, providers should continue to submit requests for APAP, BiPAP, and CPAP machines and replacement supplies using the Authorizations transaction in NaviNet.

As of January 1, 2014, ordering physicians began submitting precertification requests for sleep studies and CPAP titration studies in a facility setting through the AIM ProviderPortal. These precertification processes help to ensure that our members receive care that is appropriate, safe, and affordable.

More information about this change will be communicated in future editions of Partners in Health Update.

AIM is contracted with AmeriHealth to perform precertification for select services for most managed care members.

MEDICAL


Reminder: Precertification requirement for non-emergent outpatient radiation therapy starts January 1, 2015As previously communicated, effective January 1, 2015, precertification will be required for non-emergent outpatient radiation therapy for all commercial AmeriHealth HMO members in Pennsylvania. AmeriHealth is working with CareCore National, LLC (CareCore) to manage precertification requests for non-emergent outpatient radiation therapy services. Precertification is not required when radiation therapy is rendered in the inpatient hospital setting.

To initiate precertification for non-emergent outpatient radiation therapy, a new option will be added to the NaviNet® web portal within the Authorizations transaction that will link to CareCore’s provider portal.

You can also access their provider portal directly by going to www.carecorenational.com. Once on CareCore’s portal, you will be required to create a login and password. This login will be used every time you request precertification through CareCore. If you already have access to CareCore’s portal, please use your current login information.

For precertification requests for dates of service on or after January 1, 2015, you can call CareCore directly at 1-866-686-2649 or submit the request via NaviNet starting December 16, 2014.

In April 2015, precertification requests for non-emergent outpatient radiation therapy will also be reviewed for medical necessity. A medical policy will be forthcoming that will include a list of all the codes requiring precertification through CareCore as well as a link to the guidelines that will be used to determine medical necessity.

Precertification for other radiology servicesPrecertification requests for all high technology diagnostic imaging services (e.g., CT, MRI, PET) will continue to be handled through the current process with AIM Specialty Health®.

For more informationLook for more information about this change in future editions of Partners in Health Update. Network radiation therapy centers will receive a letter describing the new precertification process through CareCore in greater detail.

Note: This precertification requirement does not apply to members ages 19 and younger or AmeriHealth New Jersey commercial HMO and PPO or Medicare Advantage HMO members.

AIM is contracted with AmeriHealth to perform precertification for select services for most managed care members.

CareCore tutorial webinars availableCareCore will host the following tutorial webinars about how to use their portal:

● December 10, 2014, 10 a.m. to 11 a.m. ● December 12, 2014, 10 a.m. to 11 a.m. ● December 12, 2014, 1 p.m. to 2 p.m.

If you are interested in participating, please email your contact information and preferred session date and time to [email protected].

• • • • • • •• • • • • • •• • • • • •• • • • • • •• • • • • • •

DECEMBER

2014

MEDICAL


continued on the next page

Medical and claim payment policy activity posted October 25 – November 20, 2014 Below is a listing of the policy activity that we have posted to our website from October 25 – November 20, 2014.

New policyThe following 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 date Effective date

00.01.60 Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services October 1, 2014 January 1, 2015

Updated policies The following policies have been reviewed and updated to communicate current coverage and/or reimbursement positions, reporting requirements, and other processes and procedures for doing business with AmeriHealth.

Policy # Title Type of policy change Notification date Effective date

00.01.56aNational Correct Coding Initiative (NCCI) Code Pair Edits

Coverage and/or Reimbursement Position October 1, 2014 January 1, 2015

05.00.01i

Pneumatic Compression Therapy Devices for Lymphedema and Chronic Venous Insufficiency

Medical Necessity Criteria October 20, 2014 November 19, 2014

05.00.39k Ankle-Foot/Knee-Ankle-Foot Orthoses

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

October 20, 2014 November 19, 2014

07.00.21f Allergy ImmunotherapyCoverage and/or Reimbursement Position; Medical Necessity Criteria

August 27, 2014 November 25, 2014

07.02.03h Implantable Cardiac Loop Monitor

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

October 3, 2014 January 1, 2015

07.02.12gCardiac Event Detection Monitoring (External Loop Monitoring)

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


07.05.02l

Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

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


07.07.07c Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds

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


MEDICAL


Policy # Title Type of policy change Notification date Effective date

08.00.57gComplex Regional Pain Syndrome (CRPS) Parenteral Treatments



08.00.73f Bortezomib (Velcade®)General Description, Guidelines, or Informational Update; Medical Coding; Medical Necessity Criteria


08.00.78n Self-Administered Drugs Medical Coding October 31, 2014 December 1, 2014

08.00.90d

Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)

Medical Coding; Medical Necessity Criteria October 8, 2014 November 7, 2014

08.00.93bC1 Esterase Inhibitors: Cinryze®, Berinert®, and Ruconest®



08.01.04h Preventive Immunization Medical Coding; Medical Necessity Criteria October 20, 2014 November 19, 2014

08.01.12a Repository Corticotropin (H.P. Acthar® Gel Injection)

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

August 27, 2014 November 25, 2014

09.00.36h First-Trimester Prenatal Screening for Fetal Aneuploidy Medical Coding August 13, 2014

Published November 11, 2014; Retroactively effective August 13, 2014

10.03.01ePhysical Medicine, Rehabilitation, and Habilitation Services

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


11.00.16eRadiofrequency Ablation and Cryosurgical Ablation of Lung Tumors

Coverage and/or Reimbursement Position; Medical Necessity Criteria


11.15.23cEpidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management

Coverage and/or Reimbursement Position; Medical Coding; Medical Necessity Criteria


Archived policyThe following is a policy that AmeriHealth has determined is no longer necessary to remain active.

Policy # Title Notification date Archive effective date

08.00.06g Inpatient Administration of Intravenous Dihydroergotamine Mesylate (D.H.E. 45®) October 8, 2014 January 6, 2015

To view policy activity, go to www.amerihealth.com/medpolicy and select Accept and Go to Medical Policy Online. You can also view policy activity using the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy. Be sure to check back often, as the site is updated frequently.

continued from the previous page

MEDICAL


Reminder: Upcoming changes to precertification requirements for medical benefit drugs As previously communicated, effective January 1, 2015, new precertification requirements will apply to our commercial HMO and PPO and Medicare Advantage HMO members for the medical benefit drugs listed below.

The following medical benefit drugs will be added to the precertification requirement list effective January 1, 2015:

● BeleodaqTM (belinostat); ● EntyvioTM (vedolizumab); ● Keytruda® (pembrolizumab); ● Monovisc® (high molecular weight hyaluronan) – added to AmeriHealth New Jersey only, already on Delaware and Pennsylvania list;

● nivolumab (anti-PD-1 human monoclonal antibodies)*; ● Ruconest® (recombinant C1-esterase inhibitor); ● SylvantTM (siltuximab); ● VimizimTM (elosulfase alfa) – added to AmeriHealth New Jersey only, already on Delaware and Pennsylvania list.

In addition, the following medical benefit drugs will no longer require precertification approval effective January 1, 2015:

● Aredia® (pamidronate disodium); ● Arzerra® (ofatumumab); ● Boniva® injection (ibandronate sodium); ● Ceredase® (alglucerase); ● Eloxatin® (oxaliplatin); ● Nulojix® (belatacept); ● Orthovisc® (high molecular weight hyaluronan); ● Synvisc® (hylan G-F 20); ● Synvisc-One® (hylan G-F 20).

These changes will be reflected in an updated precertification requirement list, which will be available later this month on our website at www.amerihealth.com/preapproval for providers in Pennsylvania and Delaware or at www.amerihealthnj.com/html/providers/policies.html for providers in New Jersey.

*Pending approval from the U.S. Food and Drug Administration.

AmeriHealth Medigap, our new Medicare supplement productWe are pleased to announce AmeriHealth Medigap, our new Medicare supplement product for Medicare beneficiaries in New Jersey. The Medigap plans offer beneficiaries predictable out-of-pocket costs and the freedom to use the doctors, hospitals, and specialists they want.

Beginning January 1, 2015, individuals can enroll in plans A, C, F, or N. With these plans, there are no network restrictions, no referrals required, and little to no out-of-pocket costs beyond the monthly premium.AmeriHealth Medigap plans also provide coverage throughout the United States at any provider that accepts Medicare. Some plans even include emergency coverage when members travel abroad.

With these new plans, members have access to our AmeriHealth Healthy LifestylesSM Solutions program, which offers a reimbursement of up to $150 for the cost of:

● a fitness center membership when members complete 120 workouts in 365 days;

● an approved weight loss program, including Weight Watchers® online;

● an approved program to help members quit tobacco.

Prospective AmeriHealth Medigap members are encouraged to visit www.amerihealthmedicare.com or call Customer Service at 1-866-365-5345 to learn more about available options and to check eligibility requirements.

PRODUCTS

www.amerihealth.com/preapproval

www.amerihealth.com/preapproval

PHARMACY


Important information on prescribed narcotic therapy As misuse, abuse, and overdose become more common in patients who have been prescribed narcotic therapy, health care providers and managed care organizations are faced with the challenge of controlling overutilization. The most recent data shows that more than 16,000 lives are lost each year due to opioid-related overdoses. The death toll from accidental overdose has surpassed that of motor-vehicle accidents, making it the leading cause of death for the first time in the history of the United States.1

To help facilitate more appropriate usage and prescribing, AmeriHealth will require prior authorization on all high-dose and high-potency narcotics effective January 1, 2015.

Prescribing narcotic therapyAmeriHealth encourages you to keep in mind the following information when prescribing narcotic therapy to your patients:

● The most commonly abused opioid prescription drugs are: codeine, morphine, methadone, oxycodone (Oxycontin®), hydrocodone, hydromorphone, oxymorphone, meperidine, and fentanyl.2

● The recommended maximum daily morphine equivalent dose (MED) should not exceed 120 mg per day. Above this dose, risks of physical dependence, tolerance, and adverse reactions must be balanced with the pain relief benefit as well as functionality and quality of life issues.3

● Consider the balance of long-acting and short-acting medications. The current recommendation for dosing breakthrough medication is 10 – 15 percent of the daily long-acting dose.4

● Fentanyl patches should not be used in patients without sufficient body mass. Absorption is decreased in cachetic patients because the drug accumulates in skeletal muscle and fat and is then slowly released into the blood.

● Ultram® became C-IV as of August 18, 2014. ● Hydrocodone (e.g., Vicodin®, Lortab®) became C-II on October 6, 2014. These products will no longer be able to be called in to pharmacies or be refilled. A new hardcopy prescription will need to be issued for each fill.

When additional help is needed, providers should instruct patients to contact their mental health/substance abuse services provider. Members with Magellan Behavioral Health, Inc. coverage can call 1-800-424-4238.

Look for more information on prescribing narcotic therapy in future editions of Partners in Health Update. 1 Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Noncancer Pain. Pennsylvania Medical Society.

2 www.drugabuse.gov. National Institute of Drug Abuse.3 Franklin, Gary M. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology 2014; 83; 1277-1284.

4 McPherson, Mary Lynn. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing.

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

PHARMACY


Select Drug Program® Formulary updates The Select Drug Program Formulary, which is available for commercial members, is a list of medications approved by the U.S. Food and Drug Administration that were chosen for formulary coverage based on their medical effectiveness, safety, and value. The list changes periodically as the Pharmacy and Therapeutics Committee reviews the formulary to ensure its continued effectiveness. The most recent changes are listed below.

Generic additionsThese generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the appropriate generic formulary level of cost-sharing:

Generic drug Brand drug Formulary chapter Effective date

azelastine Astepro® 6. Ear, Nose, Throat Medications May 16, 2014

budesonide Rhinocort® Aqua 6. Ear, Nose, Throat Medications May 16, 2014

diclofenac sodium Pennsaid® 9. Bone, Joint, & Muscle June 6, 2014

fenofibrate Lipofen® 4. Heart, Blood Pressure, & Cholesterol May 9, 2014

hydromorphone ER* Exalgo® 3. Pain, Nervous System, & Psych May 22, 2014

methoxsalen Oxsoralen-ultra® 5. Skin Medications June 27, 2014

oxycodone ER Oxycontin® 3. Pain, Nervous System, & Psych October 6, 2014

risedronate Actonel® 150 mg 9. Bone, Joint, & Muscle June 13, 2014

testosterone* Testim®, Vogelxo™ 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones June 20, 2014

topiramate ER Qudexy™ XR 3. Pain, Nervous System, & Psych July 11, 2014

valsartan Diovan® 4. Heart, Blood Pressure, & Cholesterol July 8, 2014

*Generic requires prior authorization.

Brand additionThis brand drug was added to the formulary as of the date indicated below and is covered at the appropriate brand formulary level of cost-sharing:

Brand drug Formulary chapter Effective dateDilantin® Infatabs® 3. Pain, Nervous System, & Psych November 1, 2014

Brand deletionsEffective January 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Generic drug Formulary chapter

Actonel® 150 mg risedronate 9. Bone, Joint, & Muscle

Astepro® azelastine 6. Ear, Nose, Throat Medications

Diovan® valsartan 4. Heart, Blood Pressure, & Cholesterol

Levoxyl® levothyroxine 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones

Mestinon® IR pyridostigmine 3. Pain, Nervous System, & Psych


PHARMACY




Oxsoralen-ultra® methoxsalen 5. Skin Medications

Oxycontin® oxycodone ER 3. Pain, Nervous System, & Psych

Unithroid® levothyroxine 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones

Vandazole® metronidazole 10. Female, Hormone Replacement, & Birth Control

The generic drugs for the above brand drugs are available at the generic formulary level of cost-sharing.

Effective January 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternatives Formulary chapter

Alphanate® Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol

Bebulin® Rixubis® 4. Heart, Blood Pressure, & Cholesterol

Hemofil-M® Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol

Koate®-DVI Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol

Monoclate-P® Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol

Nasonex® budesonide, fluticasone propionate 6. Ear, Nose, Throat Medications

Profilnine® Rixubis® 4. Heart, Blood Pressure, & Cholesterol

There is no generic equivalent for the above brand drugs; however, there are formulary therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate formulary level of cost-sharing.

Compound medication policy updateEffective January 1, 2015, updates will be made to the AmeriHealth pharmacy policy on compound medications. This policy is reviewed annually by the Pharmacy & Therapeutics Committee to ensure it meets the necessary standards and efficacy.

The U.S. Food and Drug Administration (FDA) defines pharmacy compounding as the practice in which pharmacists combine, mix, or alter ingredients to create unique medications that meet the specific need of an individual patient. Drugs are compounded for patients who have allergic reactions to inactive ingredients in FDA-approved medications or for those patients who require a different formulation of a medication that is not commercially available.

A compounded product is not considered medically necessary when it replicates a commercially available product (unless the commercially available product is

temporarily unavailable), contains a drug product or component that has been removed from the market because it is unsafe or not effective, or contains a drug product or component that is excluded from the member’s benefit.

Changes to the policySome of the key changes to the policy include:

● addition of the following inclusion criterium: the compound is not used for an excluded benefit (e.g., cosmetic);

● addition of authorization requirements; ● updates to applicable products.

To review the entire policy, go to www.amerihealth.com/rx and select Pharmacy Policy.

PHARMACY


Prescription drug updatesFor commercial members enrolled in an AmeriHealth prescription drug program, prior authorization and quantity limit requirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medically necessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medication based upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for a particular drug. The most recent updates are reflected below.

Drugs requiring prior authorizationThe prior authorization requirement for the following non-formulary drugs was effective at the time the drugs became available in the marketplace:

Brand drug Generic drug Formulary chapter Effective dateEloctate™ Not available 4. Heart, Blood Pressure, & Cholesterol July 14, 2014

Rasuvo™ Not available 9. Bone, Joint, & Muscle August 27, 2014

Sivextro™ Not available 1. Antibiotics & Other Drugs Used for Infection June 30, 2014

Tanzeum™ Not available 7. Diabetes, Thyroid, Steroids, & OtherMiscellaneous Hormones June 16, 2014

Zykadia™ Not available 2. Cancer & Organ Transplant Drugs May 5, 2014

Effective January 1, 2015, the following non-formulary drugs have been added to the list of drugs requiring prior authorization:

Brand drug Generic drug Formulary chapterAmbien® 5 mg, 10 mg zolpidem 5 mg, 10 mg* 3. Pain, Nervous System, & Psych

Ambien CR® 12.5 mg zolpidem ER 12.5 mg* 3. Pain, Nervous System, & Psych

Avinza® 120 mg morphine sulfate ER 120 mg* 3. Pain, Nervous System, & Psych

Corifact® Not available 4. Heart, Blood Pressure, & Cholesterol

Dilaudid® 4 mg, 8 mg hydromorphone 4 mg*, 8 mg* 3. Pain, Nervous System, & Psych

Diovan® valsartan 4. Heart, Blood Pressure, & Cholesterol

Diovan HCT® valsartan/hctz 4. Heart, Blood Pressure, & Cholesterol

Doral® quazepam 3. Pain, Nervous System, & Psych

Duragesic® 25 mcg, 50 mcg, 75 mcg, 100 mcg

fentanyl patches 25 mcg*, 50 mcg*, 75 mcg*, 100 mcg* 3. Pain, Nervous System, & Psych

First Testosterone® Not available 7. Diabetes, Thyroid, Steroids, & OtherMiscellaneous Hormones

Halcion® triazolam 3. Pain, Nervous System, & Psych

Kadian® 60 mg, 80 mg, 100 mg morphine sulfate ER 60 mg*, 80 mg*, 100 mg* 3. Pain, Nervous System, & Psych

Kadian® 200 mg Not available 3. Pain, Nervous System, & Psych

Lunesta® 1 mg, 2 mg, 3 mg eszopiclone 1 mg, 2 mg, 3 mg* 3. Pain, Nervous System, & Psych

Not available morphine sulfate IR 30 mg* 3. Pain, Nervous System, & Psych

MS Contin® 60 mg,100 mg, 200 mg morphine sulfate ER 60 mg*, 100 mg*, 200 mg* 3. Pain, Nervous System, & Psych


PHARMACY



Nasonex® Not available 6. Ear, Nose, Throat Medications

Opana® 10 mg oxymorphone 10 mg* 3. Pain, Nervous System, & Psych

Opana ER® 20 mg, 30 mg, 40 mg Not available 3. Pain, Nervous System, & Psych

Oxycontin® 30 mg, 40 mg, 60 mg, 80 mg

oxycodone ER 30 mg*, 40 mg*, 60 mg*, 80 mg* 3. Pain, Nervous System, & Psych

Regimex® Not available 3. Pain, Nervous System, & Psych

Restoril® temazepam 3. Pain, Nervous System, & Psych

Roxicodone® 30 mg oxycodone 30 mg* 3. Pain, Nervous System, & Psych

Saphris® Not available 3. Pain, Nervous System, & Psych

Sonata® zaleplon 3. Pain, Nervous System, & Psych

Targretin® Gel Not available 2. Cancer & Organ Transplant Drugs


Effective January 1, 2015, the following drug categories have been added to the list of drugs requiring prior authorization, and these requirements apply to all members:

Category

Compound products containing any prescription bulk chemical

Compound products with total ingredient cost equal to or greater than $150 per prescription

Drugs requiring prior authorization with new criteriaEffective January 1, 2015, current members taking these medications will require a new prior authorization:


Exalgo® hydromorphone ER* 3. Pain, Nervous System, & Psych

Nucynta® 100 mg Not available 3. Pain, Nervous System, & Psych

Nucynta ER® 150 mg, 200 mg, 250 mg Not available 3. Pain, Nervous System, & Psych


Drugs with quantity limitsEffective January 1, 2015, quantity limits will be added for the following drugs:

Brand drug Generic drug Quantity limit

Ambien CR® zolpidem tartrate ER 30 tabs per 30 days

Conzip® Not available 30 caps per 30 days

Evzio™ Not available 4 units per 30 days

Nuvaring® Not available 1 ring per 28 days

Rozerem® Not available 30 tabs per 30 days

Sivextro™ Not available 6 tabs per 6 days



PHARMACY


Brand drug Generic drug Quantity limit

Ultracet® tramadol/acetaminophen 40 tabs per 5 days

Ultram® tramadol 240 tabs per 30 days

Ultram ER® tramadol ER 30 tabs per 30 days

Zutripro® hydrocodone/chlorpheniramine/pseudoephedrine 450 ml per 30 days; 15 ml per day

Drugs no longer requiring prior authorizationEffective November 1, 2014, prior authorization was removed for the following drugs:


Actoplus Met XR® pioglitazone hcl/metformin hcl 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones

Nucynta® 50 mg, 75 mg Not available 3. Pain, Nervous System, & Psych

Nucynta ER® 50 mg, 100 mg Not available 3. Pain, Nervous System, & Psych

For additional information on pharmacy policies and programs, please visit www.amerihealth.com/rx for providers in Pennsylvania and Delaware or www.amerihealthnj.com/html/providers/pharmacy for providers in New Jersey.


Nasonex® to be removed from Select Drug Program® Formulary Effective January 1, 2015, Nasonex® will be removed from the Select Drug Program Formulary. This change will move the drug from tier 2 (formulary level of cost-sharing) to tier 3 (non-formulary level of cost-sharing). Additionally, Nasonex® will require prior authorization. Generic intranasal corticosteroids, such as fluticasone, flunisolide and budesonide, are available at tier 1, the lowest level of cost-sharing, with no requirement for prior authorization. While there are over-the-counter (OTC) products available, they are not covered under the pharmacy benefit.

Please discuss the generic intranasal corticosteroid alternatives and the proper use of prescription and OTC products with your patients to determine the most appropriate plan of action.

QUALITY MANAGEMENT


2014-2015 Member Wellness Guidelines now availableWe recently posted the 2014-2015 Member Wellness Guidelines, which replaces the previous version.

The goal of these guidelines is to provide members with a user-friendly version of evidence-based guidelines for preventive health in average-risk persons. We encourage you to review these recommendations with your AmeriHealth patients to determine which screenings would be appropriate based on specific patient medical and psychosocial needs.

The guidelines are updated annually based on changes made to nationally recognized sources. Changes are reviewed by internal and external consultants, as appropriate, and by the AmeriHealth Quality Committee, which is comprised of network physicians.

You can access the 2014-2015 Member Wellness Guidelines on our website at www.amerihealth.com/clinicalguidelines. Paper copies can be ordered by submitting an online request at www.amerihealth.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

Standards for medical record documentationDocumentation of preventive health screenings is an essential part of comprehensive quality care. In addition to keeping medical records for patients’ regular checkups, it is important to have a record for those patients that are seen only when they come in for acute care visits, and for those patients that you see at multiple visits for management of chronic conditions.

Some practices use a separate form designed specifically for a patient’s well-visit to capture physical evaluation and preventive care assessments. This allows for accurate tracking of preventive care screenings and routine health assessment documentation.

The following tips can help you maintain the necessary medical record documentation:

● Remember to review preventive health and cancer screenings with each patient on an annual basis.

● Prior to scheduled visits, review Clinical Alerts provided by AmeriHealth via the NaviNet® web portal to identify and address gaps in care.

● Remind female patients with HMO insurance about Direct Access OB/GYNSM and mammography screenings.

For practices that use electronic medical records (EMR), finding a program that contains specific screens to capture preventive health care measures may be helpful in providing consistent, quality care to your patients.

For more information on Clinical Alerts, review the Viewing Clinical Alerts and Clinical Care Reports guide, located in the NaviNet Transaction Changes section of our System and Process Changes site at www.amerihealth.com/pnc/changes.

Standards for maintaining appropriate medical records can be found in the Provider Manual for Participating Professional Providers (Provider Manual), available in the Current Publications section of AmeriHealth NaviNet Plan Central. A paper copy of the Provider Manual can be ordered by submitting an online request at www.amerihealth.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

Wellness guidelines for all agesLive healthy, stay safe

www.amerihealth.com

QUALITY MANAGEMENT


The AmeriHealth Quality Management Program promotes quality of care and serviceAmeriHealth is dedicated to maintaining the highest standard of care and service for our members, providers, and the communities we serve. Information about our Quality Management Program is accessible on our website at www.amerihealth.com/providers under Resources for Patient Management. The website includes a description of the AmeriHealth Quality Management Program, including program goals, objectives, and activities to improve clinical, network, and service quality.

● Access and availability standards. AmeriHealth standards ensure that our managed care networks are adequate to meet the needs of our members with respect to location and appointment accessibility for primary and specialty care as well as urgent and emergency care in accordance with applicable regulatory requirements.

● Member rights and responsibilities. All AmeriHealth members have defined rights and responsibilities.

● Privacy and confidentiality. AmeriHealth, our contractors, and our affiliates are required to protect the privacy and confidentiality of our members’ personal and health information in accordance with state and federal regulatory requirements.

● Utilization review. It is the policy of AmeriHealth that all utilization review decisions are based on the appropriateness of health care services and supplies, in accordance with the AmeriHealth definition of medical necessity and the benefits available under the member’s coverage.

● Medical record-keeping standards. Well-maintained medical records are critical to facilitate communication, continuity, coordination, and an effective plan of care. Accordingly, AmeriHealth standards require that medical records are maintained in a manner that is current, detailed, and organized as required by applicable regulatory requirements.

Please review the standards listed above with your office staff to ensure that your office maintains the required access, documentation, and quality care expected of our network providers.

Information about our Quality Management Program and these standards can also be found in the Provider Manual for Participating Professional Providers (Provider Manual) and the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual), which are available through the NaviNet® web portal. Paper copies of the Provider Manual and Hospital Manual can be ordered by submitting an online request at www.amerihealth.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

For more information about our Quality Management Program and our progress in meeting program goals, please visit our website or contact Customer Service at 1-800-275-2583 for providers in Pennsylvania and Delaware or 1-888-YOUR-AH1 (1-888-968-7241) for providers in New Jersey. Members may request the same information by calling Customer Service.

QUALITY MANAGEMENT


2014-2015 Clinical Practice Guideline Summary now availableWe recently posted the 2014-2015 Clinical Practice Guideline Summary, which replaces the previous version. The revised summary includes a listing of all Clinical Practice Guidelines adopted by AmeriHealth that are considered the accepted minimum standard of care in the medical profession. Adherence to these guidelines may lead to improved patient outcomes.

Guidelines are available for the following medical and behavioral health conditions: asthma, chronic obstructive pulmonary disease (COPD), coronary heart disease, diabetes, heart failure, obesity, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, depression, and substance abuse disorders.

Changes in the 2014-2015 Clinical Practice Guideline Summary include: ● Asthma. New quick reference guide for providers and Asthma Action Plan for distribution to patients. ● Coronary Heart Disease. New guidelines for the management of high blood pressure (JNC8), cholesterol, and treatment of anemia in patients with heart disease.

● Diabetes. New summary of revisions to the Standards of Medical Care in Diabetes — 2014, and removed guidelines for gestational diabetes (covered under Standards of Medical Care in Diabetes).

● Heart Failure. New guideline for the management of heart failure. ● Obesity. New guideline for the management of overweight and obesity in adults.

Individual clinical decisions should be tailored to specific patient medical and psychosocial needs. As national guideline recommendations evolve, please update your practice accordingly. The summary provides a reference for each condition and links directly to the guidelines.

We update the guidelines annually based on changes made to nationally recognized sources. Changes are reviewed by internal and external consultants, as appropriate, and by the AmeriHealth Quality Committee, which is comprised of network physicians.

You can access the 2014-2015 Clinical Practice Guideline Summary at www.amerihealth.com/clinicalguidelines. Paper copies of the summary can be ordered by submitting an online request at www.amerihealth.com/providersupplyline or by calling the Provider Supply Line at 1-800-858-4728.

www.amerihealth.com/providersupplyline

www.amerihealth.com/providersupplyline

QUALITY MANAGEMENT


This article series is a monthly tool to help physicians maximize patient health outcomes in accordance with NCQA’s1 HEDIS®2 measurements for high quality care on important dimensions of services. Go to www.amerihealth.com/providers/resources/hedis.html to view previously published topics. If you have feedback or would like to request a topic, email us at [email protected].

HEDIS® definitionFollow-up care for children prescribed ADHD medication: The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed.

Two rates are reported: ● Initiation Phase. The percentage of members ages 6 – 12 as of the IPSD* with an ambulatory prescription dispensed for ADHD medication who had one follow-up visit with a practitioner prescribing authority during the 30-day Initiation Phase.

● Continuation and Maintenance (C&M) Phase. The percentage of members ages 6 – 12 as of the IPSD with an ambulatory prescription dispensed for ADHD medication who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

Why this measure is importantADHD is one of the more common chronic conditions of childhood. Children with ADHD may experience significant functional problems, such as school difficulties; academic underachievement; troublesome relationships with family members and peers; and behavioral problems. Given the high prevalence of ADHD among school-aged children (4 – 12 percent), primary care clinicians will regularly encounter children with ADHD and should have a strategy for diagnosing and long-term management of this condition.

Practitioners can convey the efficacy of pharmacotherapy to their patients. American Psychiatric Association (APA) guidelines recommend that once a child is stable, an office visit every three to six months allows assessment of learning and behavior. Follow-up appointments should be made at least monthly until the child’s symptoms have been stabilized. — NCQA, HEDIS 2013 V1

* The IPSD, or Index Prescription Start Date, is the earliest prescription dispensing date for an ADHD medication where the date is in the Intake Period and there is a Negative Medication History.

1 The National Committee for Quality Assurance (NCQA) is the most widely recognized accreditation program in the U.S.

2 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.

ADHD medicationsThe chart below indicates the percentage of physicians, by specialty type, prescribing ADHD medications.

In a six-month prescriber review for measure-qualifying ADHD medications, 71 percent of prescriptions were written by pediatricians and psychiatrists.

Increasing the follow-up rates for these two specialties could drastically improve overall measure improvement.

Highlighting HEDIS®: Follow-up care for children prescribed ADHD medication

*The Provider Automated System will be phased out for AmeriHealth Pennsylvania members as they are 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 and DE only)

Case Management 1-800-313-8628 (NJ only) 1-800-275-2583 (PA and DE only)

ConnectionsSM Health Management Program 1-888-YOUR-AH1 (968-7241) (NJ only) n/a

Condition Management n/a 1-800-275-2583 (PA and DE only)

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 and DE 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 and DE only)

NaviNet® web portal

AmeriHeatlh eBusiness Hotline 609-662-2565 (NJ only) 215-640-7410 (PA and DE 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

Documents

SM December 2014 - AmeriHealth · Billing Professional ... 2015 Medical and claim payment policy activity posted October 25 – November 20, 2014 ... Beginning in early 2015, we will