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Amerigroup Community Care complies with all applicable federal and state civil rights laws, rules and regulations and does not discriminate against
members/participants in the provision of services on the basis of race, color, national origin, religion, sex, age or disabil ity. To report a discrimination
complaint or to request language, communication or disability assistance for a member/participant, call 1 -800-600-4441. Information about civil
rights laws can be found on our website and is available from the U.S. Department of Health and Human Services.
z October 2019 TN-NB-0223-19-A
October 2019
Table of Contents Medicaid: InterQual 2019 update Page 2
Offenses involving elderly adults Page 2
Billing appropriate modifiers for 340B-acquired drugs Page 2
Medical drug Clinical Criteria updates Page 3
New clinical guideline: pneumatic compression devices, effective December 1, 2019 Page 3
Sterilization Consent Form instructions update Page 4
Prior authorization requirements changes effective November 1, 2019 Page 4
Medical Policies and Clinical Utilization Management Guidelines update Page 6
Member rights and responsibilities Page 11
Providers CARE Survey Page 13
Medicare Advantage: Prior authorization requirements changes effective November 1, 2019 Page 15
Medical drug Clinical Criteria updates Page 15
Pharmacy benefit manager change to IngenioRx Page 15
Aspire Telehealth Palliative Care program Page 16
Medicare preferred continuous glucose monitors Page 17
Introducing a new fall risk program Page 17
Update: 2019 risk adjustment provider trainings Page 18
Lowering health risks with no-cost statins Page 19
Assisting your patients in managing the Donut Hole Page 20
Prior authorization requirements for continuous positive airway pressure supplies Page 21
Changes to PA requirements Page 22
Customizations to the 23rd edition of the MCG Care Guidelines Page 23
Medical Policies and Clinical Utilization Management Guidelines update Page 23
Clinical Laboratory Improvement Amendments for Amerigroup Page 28
Special Section: Long-Term Services and Supports (LTSS): LTSS Provider Claims Corner Page 30
Employment and Community First CHOICES upcoming employment training Page 30
Disability Mentoring Day announcement Page 31
People with disabilities now eligible for Internet Essentials from Comcast Page 31
Amerigroup Foundation partners with Chattanooga -area organization for Adaptive Water Sports Day Page 32
Electronic visit verification system reminder Page 33
Reimbursement Policies: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Page 35
Drug Screen Testing Page 35
Page 2 of 35
Medicaid:
InterQual 2019 update
The effective date for Amerigroup Community Care to use InterQual® 2019 criteria has been updated from May 1, 2019, located in this Provider NewsBlast to October 31, 2019. On this
effective date, Amerigroup providers should begin using InterQual 2019 criteria and can access the criteria by logging into the provider portal.
TN-NB-0210-19-A
Offenses involving elderly adults
Effective July 1, 2019, Tennessee Code Annotated, title 39, chapter 15, part 5, has been amended as follows:
A person or entity commits an offense if the person or entity knowingly:
o Uses a telephone or other communication or electronic device to obtain information concerning the medical condition or health of an elderly adult;
o Sends, or causes to be sent, medical supplies, medical equipment or medicine to an elderly adult, and the items sent are unsolicited or specifically refused; and
o Files a claim or submits a bill with the state Medicaid plan for reimbursement of the
value of the equipment, supplies or medicine sent to the elderly adult.
Any person who violates this section shall be punished as provided in § 71-5-2601(a)(4).
TN-NB-0220-19
Billing appropriate modifiers for 340B-acquired drugs Amerigroup Community Care included a notice in the February 2019 Provider Newsletter titled Billing Appropriate Modifiers for 340B-Acquired Drugs under the Hospital Outpatient
Prospective Payment System. This article stated, “Designated hospitals are required to report appropriate modifiers for 340B-acquired drugs on bill-type 13X outpatient prospective payment system (OPPS) claims.”
Please disregard this prior notice. We received feedback that it caused confusion and would like to provide some additional information:
As of January 1, 2018, all providers must bill the appropriate modifier to identify 340B-acquired drugs.
CMS established the following modifiers to report and identify 340B-acquired drugs: o Modifier JG — drug or biologic acquired with 340B-drug pricing program
discount
o Modifier TB — drug or biologic acquired with 340B-drug pricing program discount, reported for informational purposes
Claims received and adjudicated without the appropriate modifier or with an invalid modifier may result in recoupment or a refund request.
TN-NB-0221-19
Page 3 of 35
Medical drug Clinical Criteria updates
Quarter one On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for
Amerigroup Community Care. These policies were developed, revised or reviewed to support clinical coding edits.
Effective dates are reflected in the Clinical Criteria Q1 web posting.
TN-NB-0198-19
Quarter two
On March 29, 2019, April 12, 2019, and May 1, 2019, the Pharmacy and Therapeutic (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Amerigroup Community Care. These policies were developed, revised or reviewed to support
clinical coding edits. Effective dates are reflected in the Clinical Criteria Q2 web posting.
TN-NB-0205-19
New clinical guideline: pneumatic compression devices, effective December 1, 2019
Amerigroup Community Care will implement the following clinical guideline effective December 1, 2019, to support the review of outpatient pneumatic compression devices (PCDs) after outpatient orthopedic procedures.
Federal and state law, as well as state contract language and CMS guidelines, incl uding definitions and specific contract provisions/exclusions, take precedence over these prior
authorization rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs: This document addresses the use of PCDs for the prevention of deep vein thrombosis (DVT) of the lower limbs. This therapy involves the use of an inflatable garment and
an electrical pneumatic pump. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. PCDs are used in clinics, or can be purchased or rented for home use for prevention and treatment of a number of conditions . This document
only addresses the home use of PCDs for post-outpatient orthopedic procedures.
The Clinical Criteria is publicly available on our provider website. Visit Clinical Criteria to search for specific policies.
Please submit your questions to email.
Page 4 of 35
Note: This document addresses devices for the prevention of DVT only. Pneumatic devices used in the treatment or prevention of lymphedema, venous insufficiency or therapy for musculoskeletal injuries are not addressed in this document, nor are devices for prevention of
DVT post-major surgical procedures. Not medically necessary
The use of PCDs for prevention of thromboembolism of the lower-limbs following outpatient orthopedic surgery is considered not medically necessary for all indications.
TN-NB-0213-19
Sterilization Consent Form instructions update The Division of TennCare is in the process of updating the Sterilization Consent Form
instructions in the Miscellaneous Provider Forms section of their website. What is the impact of this change? The current instructions state, “Make sure that the form you are using is the current version by
checking for the expiration date which is located in the top right-hand corner.”
CMS has informed the Division of TennCare of the following: “The sterilization consent form is codified in regulation at 42 CFR §441.258 and §441.259. The form required by regulation must be used regardless of whether there is a current OMB date. Because the form is codified in
regulation it never expires. The expiration date now on the sterilization form will continue to be renewed with new dates but for Medicaid purposes the form does not require an expiration date to be valid. This is the only form that can be used and it may not be altered in any way. The lack of a current form is not a valid reason to deny a claim providing the form has not been
altered and is compliant with regulations.
What does this mean to you? Amerigroup Community Care will only deny a claim if the consent form is not properly completed and signed. If the form is altered, it becomes invalid.
TN-NB-0212-19
Prior authorization requirements changes effective November 1, 2019
Effective November 1, 2019, prior authorization (PA) requirements will change for the following
services. These services will require PA by Amerigroup Community Care for Medicaid and Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract
provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims. PA requirements will be added to the following codes:
Page 5 of 35
0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training,
configuration of monitor
0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
33271 — Insertion of subcutaneous implantable defibrillator electrode
77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
81205 — BCKDHB (Branched Chain Keto Acid Dehydrogenase E1, beta polypeptide) (e.g., Maple Syrup Urine Disease) gene analysis, common variants (e.g., R183P, G278S, E422X)
81219 — CALR (Calreticulin) (e.g., Myeloproliferative Disorders), gene analysis, common variants in exon 9
81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, Von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)
81302 — MECP2 (methyl CpG binding protein 2) (e.g., Rett Syndrome) gene analysis; full
sequence analysis
81303 — MECP2 (methyl CpG binding protein 2) (e.g., Rett Syndrome) gene analysis; known familial variant
81304 — MECP2 (methyl CpG binding protein 2) (e.g., Rett Syndrome) gene analysis; duplication/deletion variants
81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi Syndrome and/or Angelman Syndrome), methylation analysis
81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin
protein ligase E3A) (e.g., Prader-Willi Syndrome and/or Angelman Syndrome), methylation analysis
81400 — Molecular Pathology Procedure, Level 1 (e.g., identification of single germline variant e.g., SNP by techniques such as restriction enzyme digestion or melt curve
analysis) ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (e.g., medium chain acyl dehydrogenase deficiency)
Page 6 of 35
81401 — Molecular Pathology Procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine
kinase) (e.g., acquired imatinib resistance)
81402 — Molecular Pathology Procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants
1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
81402 — Molecular Pathology Procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g.,
congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
81407 — Molecular Pathology Procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons,
sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage -gated, type 1, alpha subunit) (e.g., generalized epilepsy with febrile seizures), full gene sequence
81408 — Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (e.g., Marfan Syndrome), full gene sequence NF1 (neurofibromin 1) (e.g., neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (e.g., malignant hyperthermia), full gene
sequence VWF (von Willebrand factor) (e.g., von Willebrand Disease types 1 and 3), full gene sequence
97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
C9042 — Injection, Bendamustine hcl (belrapzo), 1 mg
C9043 — Injection, Levoleucovorin, 1 mg
C9141 — Injection, Factor VIII, (Antihemophilic Factor, recombinant), pegylated-aucl (jivi)
D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
D9920 — or management, by report
J9999 — Not otherwise classified, antineoplastic drugs
S3850 — Genetic testing for Sickle Cell Anemia
To request PA, you may use one of the following methods:
Web: https://www.availity.com
Fax: 1-800-964-3627
Phone: 1-800-454-3730
Not all PA requirements are listed here. Detailed PA requirements are available to providers on our provider website (https://providers.amerigroup.com/TN > Provider Resources & Documents > Quick Tools > Precertification Lookup Tool) and at https://www.availity.com.
Providers may also call us at 1-800-454-3730 for PA requirements.
Page 7 of 35
TN-NB-0200-19
Medical Policies and Clinical Utilization Management Guidelines update
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification
requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only with the exception of injectable or infusion drugs.
Please share this notice with other members of your practice and office staff. To view a guideline, visit https://medicalpolicies.amerigroup.com/am_search.html.
March 2019 update Notes/updates:
CG-DME-44 — Electric Tumor Treatment Field (TTF) was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.
CG-MED-72 — Hyperthermia for Cancer Therapy was revised to clarify medically
necessary (MN) and NMN statements addressing frequency of treatment.
CG-SURG-09 — Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.
CG-SURG-30 — Tonsillectomy for Children with or without Adenoidectomy was revised to:
o Spell out number of episodes of throat infections in MN criteria (A1, A2, A3). o Clarify criterion addressing parapharyngeal abscess (B4) to say two or more. o Add “asthma” as potential condition improved by tonsillectomy in MN criteria
(C1b).
The following AIM Specialty Health® updates took effect on September 28, 2019: o Advanced Imaging
Imaging of the Brain
Imaging of the Extremities Imaging of the Spine
Medical Policies On March 21, 2019, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Amerigroup Community Care.
Publish date Medical
Policy # Medical Policy title New or
revised 4/24/2019 MED.00127 Chelation Therapy New 4/24/2019 GENE.00050 Gene Expression Profiling for Coronary Artery Disease New 4/24/2019 MED.00128 Insulin Potentiation Therapy New 4/24/2019 SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing New
Page 8 of 35
3/28/2019 DRUG.00088 Atezolizumab (Tecentriq®) Revised 3/28/2019 DRUG.00053 Carfi lzomib (Kyprolis®) Revised 4/24/2019 GENE.00045 Detection and Quantification of Tumor DNA Using Next Generation Sequencing
in Lymphoid Cancers Revised
4/24/2019 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
Revised
4/24/2019 SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
Revised
4/24/2019 GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent Revised 4/24/2019 SURG.00121 Transcatheter Heart Valve Procedures Revised
Clinical UM Guidelines On March 21, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Amerigroup. These guidelines were adopted by the medical operations committee for members
on May 7, 2019.
Publish date Clinical UM Guideline #
Clinical UM Guideline title New or revised
3/28/2019 CG-ANC-07 Inpatient Interfacility Transfers Revised 3/28/2019 CG-DRUG-50 Paclitaxel, protein-bound (Abraxane®) Revised 3/28/2019 CG-DRUG-96 Ado-trastuzumab emtansine (Kadcyla®) Revised 3/28/2019 CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules Revised 4/24/2019 CG-DME-44 Electric Tumor Treatment Field (TTF) Revised 4/24/2019 CG-DRUG-68 Bevacizumab (Avastin®) for Non-Ophthalmologic Indications Revised 4/24/2019 CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays
Previous title: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
Revised
4/24/2019 CG-GENE-05 Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy)
Revised
4/24/2019 CG-MED-82 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
New
4/24/2019 CG-MED-83 Level of Care: Specialty Pharmaceuticals New 4/24/2019 CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy Revised 5/9/2019 CG-DRUG-113 Inotuzumab ozogamicin (Besponsa®) New 5/9/2019 CG-GENE-06 Preimplantation Genetic Diagnosis Testing New 5/9/2019 CG-GENE-07 BCR-ABL Mutation Analysis New 5/9/2019 CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome New 5/9/2019 CG-GENE-09 Genetic Testing for CHARGE Syndrome New 5/9/2019 CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications New 5/9/2019 CG-SURG-98 Prostate Multiparametric Magnetic Resonance Imaging New 5/9/2019 CG-SURG-99 Panniculectomy and Abdominoplasty New 6/24/2019 CG-SURG-97 Cardioverter Defibrillators New
TN-NB-0202-19 June 2019 update Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
*DME.00037 — Added devices that combine cooling and vibration to the Investigational
(INV) & not medically necessary (NMN) statement
*LAB.00027 — Added Mediator Release Test to INV&NMN statement.
Page 9 of 35
*LAB.00033 — Clarified INV&NMN statement to include 4Kscore and AR-V7
*OR-PR.00003: o Clarified medically necessary (MN) position statement criteria 2 to 4 o Added statement that use of prosthetic devices that combine both a
microprocessor controlled knee and foot-ankle prosthesis is considered INV&NMN for all indications
*SURG.00011: o Added new MN and INV&NMN statements addressing amniotic membrane -
derived products for conjunctival and corneal indications, including KeraSys and Prokera
o Added new products to INV&NMN statement.
*SURG.00045: o Added erectile dysfunction, Peyronie’s disease and wound repair to the
INV&NMN statement o Revised title
*SURG.00121 — Added INV&NMN statement to address use of transcatheter tricuspid valve repair or replacement for all indications
The following AIM Specialty Health® updates were approved on June 6, 2019: o Advanced Imaging:
Imaging of the Heart Oncologic Imaging Vascular Imaging
o Proton Beam Therapy
o Rehabilitative Therapies — Physical Therapy, Occupational Therapy and Speech Therapy (New)
Medical Policies On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Amerigroup Community Care.
Publish date Medical
Policy # Medical Policy title New or
revised 6/13/2019 MED.00129 Gene Therapy for Spinal Muscular Atrophy New 6/13/2019 GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome Revised 6/13/2019 *SURG.00011 Allogeneic, Xenographic, Synthetic, and Composite Products for Wound
Healing and Soft Tissue Grafting Revised
6/13/2019 SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
Revised
6/13/2019 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
Revised
6/27/2019 GENE.00025 Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors
Revised
6/27/2019 DRUG.00046 Ipilimumab (Yervoy®) Revised 6/27/2019 DRUG.00053 Carfi lzomib (Kyprolis®) Revised 6/27/2019 DRUG.00062 Obinutuzumab (Gazyva®) Revised 6/27/2019 DRUG.00067 Ramucirumab (Cyramza®) Revised 6/27/2019 DRUG.00071 Pembrolizumab (Keytruda®) Revised 6/27/2019 DRUG.00075 Nivolumab (Opdivo®) Revised
Page 10 of 35
Publish date Medical Policy #
Medical Policy title New or revised
6/27/2019 DRUG.00107 Avelumab (Bavencio®) Revised 6/27/2019 GENE.00044 Analysis of PIK3CA Status in Tumor Cells Revised 6/27/2019 *SURG.00121 Transcatheter Heart Valve Procedures Revised 6/27/2019 GENE.00001 Genetic Testing for Cancer Susceptibility Revised 6/27/2019 GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases Revised 6/27/2019 LAB.00011 Analysis of Proteomic Patterns Revised 6/27/2019 LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for
Cancer Revised
7/10/2019 GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
New
7/10/2019 SURG.00153 Cardiac Contractility Modulation Therapy New 7/10/2019 *DME.00037 Cooling Devices and Combined Cooling/Heating Devices Revised 7/10/2019 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS)
Devices Revised
7/10/2019 GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment Revised 7/10/2019 *LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests Revised 7/10/2019 *LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate
Cancer Revised
7/10/2019 MED.00109 Corneal Collagen Cross-Linking Revised 7/10/2019 *OR-
PR.00003 Microprocessor Controlled Lower Limb Prosthesis Revised
7/10/2019 SURG.00005 Partial Left Ventriculectomy Revised 7/10/2019 *SURG.00045 Extracorporeal Shock Wave Therapy
Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions Revised
7/10/2019 SURG.00120 Internal Rib Fixation Systems Revised 9/4/2019 GENE.00010 Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-
Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
Revised
Clinical UM Guidelines On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Amerigroup. These guidelines were adopted by the medical operations committee for TennCare
members on July 5, 2019.
Publish date Clinical UM Guideline #
Clinical UM Guideline title New or revised
6/24/2019 CG-SURG-97 Cardioverter Defibrillators New 6/27/2019 CG-DRUG-48 Azacitidine (Vidaza®) Revised 6/27/2019 CG-DRUG-62 Fulvestrant (FASLODEX®) Revised 6/27/2019 CG-DRUG-106 Brentuximab Vedotin (Adcetris) Revised 6/27/2019 CG-DRUG-98 Bendamustine Hydrochloride Revised 6/27/2019 CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder and
Chronic Pain Revised
6/27/2019 CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting Revised 7/10/2019 CG-SURG-100 Laser Trabeculoplasty and Laser Peripheral Iridotomy New 7/10/2019 CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment Review
Medical Necessity Determinations When No Other Clinical UM Guideline Exists
Revised
7/10/2019 CG-ANC-06 Ambulance Services: Ground; Non-Emergent Revised 7/10/2019 CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy Revised
Page 11 of 35
Publish date Clinical UM Guideline #
Clinical UM Guideline title New or revised
7/10/2019 CG-DME-07 Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
Revised
7/10/2019 CG-DME-08 Infant Home Apnea Monitors Revised 7/10/2019 CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices Revised 7/10/2019 CG-DME-42 Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices Revised 7/10/2019 CG-DME-45 Ultrasound Bone Growth Stimulation Revised 7/10/2019 CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility
Setting Revised
7/10/2019 CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
Revised
7/10/2019 CG-MED-57 Cardiac Stress Testing with Electrocardiogram Revised 7/10/2019 CG-MED-59 Upper Gastrointestinal Endoscopy in Adults Revised 7/10/2019 CG-SURG-11 Surgical Treatment for Dupuytren's Contracture Revised 7/10/2019 CG-SURG-17 Trigger Point Injections Revised 7/10/2019 CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI) Revised 7/10/2019 CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial
Revascularization of the Lower Extremities Revised
7/10/2019 CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants Revised 7/10/2019 CG-SURG-85 Hip Resurfacing Revised 7/10/2019 CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access
Circuit Dysfunction Revised
9/4/2019 CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
New
9/4/2019 CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
New
9/4/2019 CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus New 9/4/2019 CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy New
TN-NB-0211-19
Member rights and responsibilities Members have rights and responsibilities when participating with an MCO. Our Member
Services representatives are advocates for our members. The following lists the rights and responsibilities of members:
Members have the right to:
Be treated with respect with due consideration for dignity and privacy
Participate in Amerigroup Community Care without being discriminated against on the basis of handicap and/or disability, age, race, color, religion, sex, national origin, or any other classification protected under applicable federal and state laws
Privacy during a visit with their doctor
Talk about their medical record with their PCP and ask for a summary of that record and request to amend or correct the record as appropriate
Be properly educated about and helped to understand their illnesses and the available health care options
Page 12 of 35
Have a candid discussion with their provider of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage
Participate in decision-making about the health care services they receive
Refuse health care (to the extent of the law) and understand the consequences of their
refusal
Be free from any form of restraint or seclusion as a means of coercion, discipline, inconvenience or retaliation as specified in other federal regulations on the use of restraints and seclusion
Decide ahead of time the kinds of care they want if they become sick, injured or seriously ill by executing an advance directive
Expect that their records (including medical and personal information) and communications will be treated confidentially
If under age 18 and married, pregnant or have a child, be able to make decisions about
themselves and/or their child’s health care
Choose their PCP from the Amerigroup network of providers
Have information about Amerigroup, its services, providers, and member rights and responsibilities
Receive information on the Notice of Privacy Practices as required by HIPAA
Get a current member handbook and a provider referral directory
Choose any Amerigroup network specialist after getting a referral from their PCPs; some services do not require a referral, such as family planning
Be referred to health care providers for ongoing treatment of chronic disabilities
Have access to their PCPs or backups 24 hours a day, 365 days a year for urgent or emergency care
Get care right away from any hospital when their symptoms meet the definition of an emergency medical condition
In certain circumstances, get post-stabilization services following an emergency medical condition
Call the 24-hour Nurse HelpLine toll free 24 hours a day, 7 days a week at 1-800-600-4441
Call the Amerigroup Member Services staff toll free from 7 a.m. to 7 p.m. Central time Monday through Friday at 1-800-600-4441
Know what payment methodology Amerigroup uses with health care providers
File a medical appeal with TennCare
Freely exercise the right to file a complaint or an appeal without adversely affecting the
way members are treated
Receive notification to present supporting documentation for their complaints
Continue to receive benefits pending the outcome of appeal or fair hearing under certain circumstances
Only be responsible for cost-sharing as defined in the cost-sharing section of this manual
Make recommendations regarding the organization’s member rights and responsibilities
policies Members have the responsibility to:
Treat their doctors, their doctors’ staff and Amerigroup employees with respe ct and
dignity
Page 13 of 35
Not be disruptive in their doctor’s offices Respect the rights and property of all providers Cooperate with people providing health care
Tell their PCP and/or their treating physician about their symptoms and problems and ask questions
Get information and understand their health problems and consider treatments to
participate in developing mutually agreed upon treatment goals before services are performed
Discuss anticipated problems with following their doctor’s directions
Consider the outcome of refusing treatment recommended by a doctor Help their doctor obtain medical records from their previous doctors and help their
doctor complete new medical records as necessary
Respect the privacy of other people waiting in doctors’ offices Secure referrals from their PCPs, when specifically required, before going to another
health care provider unless they have a medical emergency
Call Amerigroup to change their PCPs before seeing any new PCPs Make and keep appointments and be on time; members should always call if they need
to cancel appointments, change appointment times or if they will be late Discuss complaints, concerns and opinions in an appropriate and courteous way
Tell their doctor who they want to receive their health information Obtain medical services from their PCPs Learn and follow the Amerigroup policies outlined in the member handbook
Read the member handbook to understand how Amerigroup works Notify TennCare if a family member who is enrolled in Amerigroup has died Notify TennCare if addresses and/or status change
Give TennCare proper identification when they enroll Become involved in their health care and cooperate with their doctor about
recommended treatment and care that they have agreed on with their doctor
Know the correct way to take their medications Carry their Amerigroup ID card at all times and report any lost or stolen cards to
Amerigroup quickly; members should contact TennCare of the Tennessee Department
of Human Services if there are changes to their name, address or marital status Show their ID cards to each provider Tell Amerigroup about any doctors they are currently seeing Notify their PCPs as soon as possible after they receive emergency services
Go to the emergency room when they have an emergency Report suspected fraud and abuse
TN-NB-0217-19
Providers CARE Survey
Good health outcomes start in the communities where your patients live. Starting September 20, 2019, we invite you to Connect with Us by taking the Providers CARE Survey.
By taking the survey, you’ll provide information about the challenges your patients are facing in their communities. Our goal is to help you improve your patients’ health by:
Page 14 of 35
C = Connecting them with community resources (like food pantries and housing help). A = Acting for better health by teaching them about their care needs. R = Reducing stigma by showing compassion to others and taking time to think about
your actions and thoughts about yourself and others. E = Empowering yourself and others. Take the time to listen to your patients. Treating
them with kindness and support can help them take the steps they need for better
health. We are here to help you Connect your patients to CARE. The CARE survey will ask you about the
needs of your patients and the learning opportunities that can assist your practice team. To fill out the survey, please visit https://www.tn.gov/tenncare/providers/social-and-health-
needs.html. Your answers will not have your name on them and will be combined with information from
other providers. Thank you for caring about the health of your community.
TN-NB-0216-19
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Medicare Advantage:
Prior authorization requirements changes effective November 1, 2019
View the full article in the Medicaid section.
TN-NB-0200-19
Medical drug Clinical Criteria updates
Quarter one View the full article in the Medicaid section. TN-NB-0198-19 Quarter two On March 29, 2019, April 12, 2019 and May 1, 2019, the Pharmacy and Therapeutic (P&T)
Committee approved Clinical Criteria applicable to the medical drug benefit for Amerigroup Community Care. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website (https://providers.amerigroup.com), and the effective dates will be reflected in the
Clinical Criteria Q2 update. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.
AGPCRNL-0038-19
Pharmacy benefit manager change to IngenioRx Effective January 1, 2020, IngenioRx will become our new pharmacy benefit manager (PBM)
and will start managing prescription coverage for your Medicare Advantage individual and group retiree plan patients. IngenioRx PBM services will include handling your patients’ prescriptions for mail order and specialty pharmacy medications.
Transferring prescriptions We will automatically transfer prescriptions to IngenioRx Home Delivery Pharmacy for patients
currently using Express Scripts Mail Order Pharmacy. Members will receive instructions for initializing IngenioRx Home Delivery Pharmacy later this year. For patients receiving specialty drugs from Accredo, we will automatically transfer prescriptions to IngenioRx Specialty
Pharmacy. Most patients will be able to fill their prescriptions at their same retail pharmacy outlet. If your patient’s pharmacy will not be available, we will notify your patient by letter and include a list of three alternative pharmacies near his or her home.
Prescriptions for controlled substances currently being filled at Express Scripts Mail Order Pharmacy or Accredo cannot be transferred to another pharmacy under federal law. Patients
Page 16 of 35
currently receiving these medications will need a new prescription sent to IngenioRx Home Delivery Pharmacy or IngenioRx Specialty Pharmacy.
For providers Then
Who use ePrescribing There are no changes — Simply select IngenioRx.
Who do not use ePrescribing You should send your mail order and specialty prescriptions to IngenioRx. IngenioRx will begin accepting prescriptions
January 1, 2020. Please consider the days’ supply of the prescription when making these requests.
IngenioRx Mail Order Pharmacy new prescriptions:
o Phone: 1-833-203-1742 o Fax: 1-800-378-0323
IngenioRx Specialty Pharmacy: o Prescriber phone: 1-833-262-1726
o Prescriber fax: 1-833-263-2871
You can confirm whether your patient has transitioned to IngenioRx through the Availity Portal.
Your patient’s PBM information can be located in the Patient Information section of their patient profile as part of the eligibility and benefits inquiry.
AGPCRNL-0048-19
Aspire Telehealth Palliative Care program
Aspire Health* for Medicare members in need of telephonic palliative care
The Aspire Telehealth Palliative Care program provides an additional layer of telephonic support to patients facing a serious illness. The program is focused on:
Helping patients understand their diagnosis.
Facilitating conversations with patients and their families around their goals of care.
Ensuring patients receive care aligned with their goals and values. The program begins with an initial 30-60 minute telephonic assessment by a specially trained Aspire Health social worker. The conversation in this initial call focuses on building rapport and
completing a comprehensive assessment. This assessment includes understanding the patient's perception of their illness and current treatment plan. Follow-up calls occur every 2-4 weeks, typically lasting 15-45 minutes, with the exact frequency based on a patient's individual need.
Aspire Health's social workers are supported by a full interdisciplinary team of board-certified palliative care physicians, nurses, and chaplains who provide additional telephonic support to patients and their families as needed. Patients enrolled in the telehealth program have access to 24/7 on-call support. The average patient is enrolled in the program for 6-8 months with
some of the key goals being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advanced care planning documents and/or a transition to
hospice when appropriate.
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More information is available at www.aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 1-844-232-0500.
AGPCRNL-0059-19
Medicare preferred continuous glucose monitors
On January 1, 2020, Amerigroup Community Care will implement a preferred edit on Medicare-
eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by
Amerigroup will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests,
call 1-833-293-0661.
AGPCRNL-0057-19
Introducing a new fall risk program
Knowing if your patient has fallen is important even if they are not hurt badly. Did you know?
Every 11 seconds, an older American is treated in an emergency room due to a fall.
Every 19 minutes, an older American dies from a fall.
About 2.8 million fall-related injuries are treated in emergency room annually. Fall risk assessments
We want to empower our members to stay safe and healthy at any age. This includes helping them reduce the risk of falling. This year, our nursing team will administer fall risk assessments for members in the Case Management program.
We will be asking members the following questions to determine their risk or fear of falling:
“Have you fallen and hurt yourself in the past year?”
“Have you fallen two or more times in the past year?”
“Do you fear falling because of balance or gait?”
“Have you spoken to your doctor about any of the above?”
As part of the interventions, we will be asking our members to speak with their doctors about falls and fall prevention.
AGPCRNL-0056-19
Update: 2019 risk adjustment provider trainings
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The Medicare Risk Adjustment Regulatory Compliance team at Amerigroup Community Care offers two provider training programs regarding Medicare risk adjustment guidelines. Information for each training is outlined below. The Medicare Risk Adjustment Regulatory
Compliance team developed the following two provider trainings. This update outlines the training series:
Medicare risk adjustment and documentation guidance (general)
When — offered the first Wednesday of each month from December 5, 2018, to November 6, 2019 at 1-2 p.m. Eastern time
Learning objective — This training will provide an overview of Medicare Risk
Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.
Credit — This activity has been reviewed and is acceptable for up to one prescribed credit by the American Academy of Family Physicians.
If you are interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:
https://antheminc.adobeconnect.com/admin/show-event-catalog?folder-id=38826374. Medicare risk adjustment, documentation and coding guidance (condition specific)
When — offered on the fourth Wednesday of every other month from January 23, 2019 to November 27, 2019 from noon- 1 p.m. Eastern time
Learning objective — This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific
conditions including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
Credit — This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians.
For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:
1. Red flag HCCs, part one — Register for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage,
aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration. https://antheminc.cosocloud.com/e4i5k4h7cf3j/event/registration.html
2. Red Flag HCCs, part two — Register for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia
gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration
https://antheminc.cosocloud.com/enfndbyedd5g/event/event_info.html .
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3. Opioids and more: substance abuse and dependence — Recording will play upon registration. https://antheminc.cosocloud.com/ekx3tooh22f7/event/registration.html
4. Acute, chronic and status conditions — Recording will play upon registration.
https://antheminc.cosocloud.com/eeq7am1fht49/event/registration.html 5. Diabetes mellitus and other metabolic disorders — September 25, 2019
https://antheminc.cosocloud.com/e9l4sxzbd2lq/event/registration.html
6. Behavioral health — November 27, 2019 https://antheminc.cosocloud.com/eatxsocnqf6h/event/registration.html
AGPCRNL-0054-19
Lowering health risks with no-cost statins Statin medications can assist your patients in lowering their cholesterol levels, reducing
cardiovascular risk and low-density lipoprotein (LDL) reduction. When evaluating your patients as candidates for statin medications, implement treatment protocols based on the American College of Cardiology/American Heart Association 2018
Guideline on the Management of Blood Cholesterol:
Cardiovascular risk reduction benefits of statin therapy go beyond cardiovascular risk and LDL reduction.
Patients with an LDL-C less than 70 should have statin therapy evaluated and
individualized based on other cardiovascular risk factors.
Patients aged less than 75 years and at risk for cardiovascular disease are recommended to have a high-intensity statin. Moderate-intensity statin therapy is recommended if the patient has a contraindication or experienced statin-associated side effects.
Ensuring your patients adhere to their prescribed statin amounts Several barriers, financial and physical, may prevent your patients from adhering to their
prescribed statin use. Remind your patients of the importance of using their prescribed medications. Communicate to
your patients:
The benefits of the medication.
The potential for side effects: o Try a lower dose or a different statin to manage any experienced side effects.
Prescribe low-cost generics to eliminate cost as a barrier and inform patients of statin medications available for $0 for up to a 90-day supply.
List of statin medications available for free with an up to 90-day supply The following medications are available for free to your patient:Simvastatin, Pravastatin, Lovastatin, Rosuvastatin, Atorvastatin
Page 20 of 35
AGPCRNL-0051-19
Assisting your patients in managing the Donut Hole
The Medicare Part D coverage gap The coverage gap, also referred to as the Donut Hole, is one of the four Medicare Part D payments stages your patients will progress through. This is the payment stage where your
patients will spend the most in out-of-pocket drug costs. Reducing drug costs Tier 6 medications
While there are programs that can assist financially during the coverage gap (such as the Medicare Extra Help program and Medicare’s Coverage Gap Discount Program), your patients may still have difficulties covering their drug costs.
Reminding your patients to never stop taking medications or making any changes to their medications without first consulting you is important. By prescribing Tier 6 medications, you
may be able to reduce total drug costs for your patients with these lower-cost generic medications.
These following medications are available on Tier 6, which are available for $0, even while your patients are in the coverage gap stage of Medicare Part D. Blood pressure medications:
Benazepril (Lotensin®): 5 mg, 10 mg, 20 mg, 40 mg
Enalapril (Vasotec®): 2.5 mg, 5 mg, 10 mg, 20 mg
Fosinopril: 10 mg, 20 mg, 40 mg
Irbesartan (Avapro®): 75 mg, 150 mg, 300 mg
Lisinopril (Prinivil® or Zestril®): 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg
Losartan (Cozaar®): 25 mg, 50 mg, 100 mg
Quinapril (Accupril®): 10 mg, 20 mg, 40 mg
Ramipril (Altace®): 1.25 mg, 2.5 mg, 5 mg, 10 mg
Trandolapril: 1 mg, 2 mg, 4 mg
Benazepril-HCTZ (Lotensin HCT®): 5-6.25 mg, 10-12.5 mg, 20-12.5 mg, 20-25mg
Enalapril-HCTZ (Vaseretic®): 5-12.5 mg, 10-25 mg
Lisinopril-HCTZ (Zestoretic® or Prinizide®): 10-12.5 mg, 20-12.5 mg, 20-25 mg
Losartan-HCTZ (Hyzaar®): 50-12.5 mg, 100-12.5 mg, 100-25 mg
Valsartan-HCTZ (Diovan HCT®): 80-12.5 mg, 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg
Diabetes medications:
Metformin (Glucophage®): 500 mg, 850 mg, 1000 mg
Metformin ER (Glucophage XR®): 500 mg, 750 mg
Glimepiride (Amaryl®): 1 mg, 2 mg, 4 mg
Glipizide (Glucotrol®): 5 mg, 10 mg
Glipizide ER (Glucotrol XL®): 2.5 mg, 5 mg, 10 mg
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Glipizide-metformin: 2.5-250 mg, 2.5-500 mg, 5-500 mg Osteoporosis medications:
Alendronate (Fosamax®): 5 mg, 10 mg, 35 mg, 40 mg, 70 mg Cholesterol medications:
Atorvastatin (Lipitor®): 10 mg, 20 mg, 40 mg, 80 mg
Lovastatin (Mevacor®): 10 mg, 20 mg, 40 mg
Pravastatin (Pravachol®): 10 mg, 20 mg, 40 mg, 80 mg
Rosuvastatin (Crestor®): 5mg, 10 mg, 20 mg, 40 mg*
Simvastatin (Zocor®): 5 mg, 10 mg, 20 mg, 40 mg, 80 mg * Rosuvastatin was added to Tier 6 in June
AGPCRNL-0050-19
Prior authorization requirements for continuous positive airway pressure supplies
Effective December 1, 2019, Amerigroup Community Care will begin requiring prior authorization for the below listed continuous positive airway pressure (CPAP) supplies. These prior authorizations will be managed through AIM Specialty Health®(AIM), a specialty health
benefits company. Amerigroup has an existing relationship with AIM in the administration of other medical management programs.
AIM will follow the Amerigroup clinical hierarchy for medical necessity determination. Amerigroup makes coverage determinations based on CMS national coverage determinations, local coverage determinations, other coverage guidelines, and instructions issued by CMS and
legislative benefit changes. Where the existing guidance provides insufficient clinical detail, AIM will make a determination of medical necessity using an objective, evidence-based process.
Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com. Contracted and noncontracted providers may call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed. The Clinical Guidelines
that have been adopted by Amerigroup to review for medical necessity are located at http://www.aimspecialtyhealth.com/marketing/guidelines/185/index.html.
Prior authorization requirements For services that are scheduled on or after December 1, 2019, providers must contact AIM to obtain prior authorization for the services detailed below. Providers are strongly encouraged to
verify that a prior authorization has been obtained before scheduling and performing services.
A4604 Tubing with heating element
A7046 Water chamber for humidifier, replacement, each A7027 Combination Oral/Nasal Mask used with positive airway pressure device, each
A7030 Full Face Mask used with positive airway pressure device, each
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A7031 Face Mask Cushion, Replacement for Full Face Mask A7034 Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head
strap
A7035 Headgear A7036 Chinstrap
A7037 Tubing
A7039 Filter, nondisposable A7044 Oral Interface for Positive Airway Pressure Therapy
A7045 Replacement Exhalation Port for PAP Therapy
A7028 Oral Cushion, Replacement for Combination Oral/Nasal Mask, each A7029 Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair
A7032 Replacement Cushion for Nasal Application Device
A7033 Replacement Pil lows for Nasal Application Device, pair A7038 Filter, disposable
AGPCRNL-0053-19
Changes to PA requirements
Beginning December 1, 2019, prior authorization (PA) requirements will change some codes covered by Amerigroup Community Care for Medicare Advantage members. Federal and state law, state contract language and CMS guidelines (including definitions and specific contract
provisions and exclusions) take precedence over these rules and must be considered first when determining coverage. Amerigroup will deny claims that are noncompliant with the new rules. PA requirements will be added to the following:
T1019 — Personal care services, per 15 minutes, not for an inpatient or resident of a
hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
C9740 — Cystourethroscopy, with insertion of transprostatic implant; 4 or more
implants
E0953 — Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware
E1031 — Rollabout chair, any and all types with castors 5 inches or greater
E1090 — High-strength lightweight wheelchair, detachable arms, desk or full -length,
swing-away detachable footrests
E1130 — Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests
E1140 — Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests
E1260 — Lightweight wheelchair, detachable arms (desk or full -length) swing-away detachable footrest
E1285 — Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest
E1290 — Heavy-duty wheelchair, detachable arms (desk or full -length) swing-away detachable footrest
E2207 — Wheelchair accessory, crutch and cane holder
E2378 — Power wheelchair component, actuator, replacement only
K0039 — Leg strap, H style
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Not all PA requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com.
Contracted and noncontracted providers who are unable to access the Availity Portal may call the number on the back of your patient’s Amerigroup ID card for PA requirements.
AGPCRNL-0043-19
Customizations to the 23rd edition of the MCG Care Guidelines
Effective November 1, 2019, customizations will be implemented for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria and guidance on the following:
Clinical indications for admission; examples will also be added for: o Aggressive hydration needs that cannot be managed in an infusion center. o Prolonged marrow suppression.
Regimens that cannot be managed outpatient; examples will also be added.
Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition.
For questions, contact Provider Services at 1-866-805-4589.
AGPCRNL-0041-19
Medical Policies and Clinical Utilization Management Guidelines update
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were
developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable
listings below are informational only with the exception of injectable or infusible drugs. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.
Please share this notice with other members of your practice and office staff. To view a guideline, visit https://providers.amerigroup.com/pages/TN.
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March 2019 Notes/updates:
CG-DME-44 — Electric Tumor Treatment Field was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.
CG-MED-72 — Hyperthermia for Cancer Therapy was revised to clarify medically necessary (MN) and NMN statements addressing frequency of treatme nt.
CG-SURG-09 — Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.
CG-SURG-30 — Tonsillectomy for Children With or Without Adenoidectomy was revised to:
o Spell out number of episodes of throat infections in MN criteria (A1, A2, A3). o Clarify criterion addressing parapharyngeal abscess (B4) to say "two or more." o Add “asthma” as potential condition improved by tonsillectomy in MN criteria
(C1b).
GENE.00043 — Genetic Testing of an Individual’s Genome for Inherited Diseases was revised to remove investigational and NMN statement and all other language and coding related to Corus CAD testing. Corus CAD testing is now addressed in GENE.00050.
The following AIM Specialty Health® updates took effect on March 31, 2019: o Advanced Imaging
Imaging of the brain Imaging of the extremities
Imaging of the spine Medical Policies On March 21, 2019, the Medical Policy and Technology Assessment Committee (MPTAC)
approved the following Medical Policies applicable to Amerigroup Community Care.
Publish date Medical Policy #
Medical Policy title New or revised
4/24/2019 MED.00127 Chelation Therapy New 4/24/2019 GENE.00050 Gene Expression Profiling for Coronary Artery Disease New 4/24/2019 MED.00128 Insulin Potentiation Therapy New 4/24/2019 SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing New 3/28/2019 DRUG.00088 Atezolizumab (Tecentriq®) Revised 3/28/2019 DRUG.00053 Carfi lzomib (Kyprolis®) Revised 4/24/2019 GENE.00045 Detection and Quantification of Tumor DNA Using Next Generation Sequencing
in Lymphoid Cancers Revised
4/24/2019 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
Revised
4/24/2019 SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
Revised
4/24/2019 GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent Revised 4/24/2019 SURG.00121 Transcatheter Heart Valve Procedures Revised
Clinical UM Guidelines On March 21, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to
Amerigroup. These guidelines were adopted by the Medical Operations Committee for Amerigroup Amerivantage (Medicare Advantage) program members on May 7, 2019.
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Publish date Clinical UM Guideline #
Clinical UM Guideline title New or revised
3/28/2019 CG-ANC-07 Inpatient Interfacility Transfers Revised 3/28/2019 CG-DRUG-50 Paclitaxel, protein-bound (Abraxane®) Revised 3/28/2019 CG-DRUG-96 Ado-trastuzumab emtansine (Kadcyla®) Revised 3/28/2019 CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules Revised 4/24/2019 CG-DME-44 Electric Tumor Treatment Field Revised 4/24/2019 CG-DRUG-68 Bevacizumab (Avastin®) for
Non-Ophthalmologic Indications Revised
4/24/2019 CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays Previous title: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
Revised
4/24/2019 CG-GENE-05 Genetic Testing for DMD Mutations (Duchenne or Becker Muscular Dystrophy)
Revised
4/24/2019 CG-MED-82 Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
New
4/24/2019 CG-MED-83 Level of Care: Specialty Pharmaceuticals New 4/24/2019 CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy Revised 5/9/2019 CG-DRUG-113 Inotuzumab ozogamicin (Besponsa®) New 5/9/2019 CG-GENE-06 Preimplantation Genetic Diagnosis Testing New 5/9/2019 CG-GENE-07 BCR-ABL Mutation Analysis New 5/9/2019 CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome New 5/9/2019 CG-GENE-09 Genetic Testing for CHARGE Syndrome New 5/9/2019 CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications New 5/9/2019 CG-SURG-98 Prostate Multiparametric Magnetic Resonance Imaging New 5/9/2019 CG-SURG-99 Panniculectomy and Abdominoplasty New 6/24/2019 CG-SURG-97 Cardioverter Defibrillators New
AGPCRNL-0045-19_TN
June 2019 update Notes/updates
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:
* DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement
* LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement
* LAB.00033 — clarified investigational and not medically necessary statement to include 4Kscore and AR-V7
* OR-PR.00003:
o Clarified medically necessary position statement criteria 2-4 o Added statement that use of prosthetic devices that combine both a
microprocessor controlled knee and foot-ankle prosthesis is considered
investigational and not medically necessary for all indications
* SURG.00011: o Added new medically necessary and investigational and not medically necessary
statements addressing amniotic membrane-derived products for conjunctival
and corneal indications, including KeraSys and Prokera o Added new products to investigational and not medically necessary statement
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* SURG.00045: o Added erectile dysfunction, Peyronie’s disease and wound repair to the
investigational and not medically necessary statement
o Revised title
* SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications
The following AIM Specialty Health® updates were approved on June 6, 2019: o Advanced imaging:
Imaging of the heart Oncologic imaging Vascular imaging
o Proton beam therapy o Rehabilitative therapies — physical therapy, occupational therapy and speech
therapy (new)
Medical Policies On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved
the following Medical Policies applicable to Amerigroup Community Care.
Publish date Medical Policy #
Medical Policy title New or revised
June 13, 2019 MED.00129 Gene Therapy for Spinal Muscular Atrophy New June 13, 2019 GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome Revised June 13, 2019 * SURG.00011 Allogeneic, Xenographic, Synthetic, and Composite Products for Wound
Healing and Soft Tissue Grafting Revised
June 13, 2019 SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
Revised
June 13, 2019 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
Revised
June 27, 2019 GENE.00025 Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies Previous title: Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors
Revised
June 27, 2019 DRUG.00046 Ipilimumab (Yervoy®) Revised June 27, 2019 DRUG.00053 Carfi lzomib (Kyprolis®) Revised June 27, 2019 DRUG.00062 Obinutuzumab (Gazyva®) Revised June 27, 2019 DRUG.00067 Ramucirumab (Cyramza®) Revised June 27, 2019 DRUG.00071 Pembrolizumab (Keytruda®) Revised June 27, 2019 DRUG.00075 Nivolumab (Opdivo®) Revised June 27, 2019 DRUG.00107 Avelumab (Bavencio®) Revised June 27, 2019 GENE.00044 Analysis of PIK3CA Status in Tumor Cells Revised June 27, 2019 * SURG.00121 Transcatheter Heart Valve Procedures Revised June 27, 2019 GENE.00001 Genetic Testing for Cancer Susceptibility Revised June 27, 2019 GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases Revised June 27, 2019 LAB.00011 Analysis of Proteomic Patterns Revised June 27, 2019 LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for
Cancer Revised
July 10, 2019 GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
New
July 10, 2019 SURG.00153 Cardiac Contractility Modulation Therapy New July 10, 2019 * DME.00037 Cooling Devices and Combined Cooling/Heating Devices Revised
Page 27 of 35
Publish date Medical Policy #
Medical Policy title New or revised
July 10, 2019 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
Revised
July 10, 2019 GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment Revised July 10, 2019 * LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests Revised July 10, 2019 * LAB.00033 Protein Biomarkers for the Screening, Detection and Management of
Prostate Cancer Revised
July 10, 2019 MED.00109 Corneal Collagen Cross-Linking Revised July 10, 2019 * OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis Revised July 10, 2019 SURG.00005 Partial Left Ventriculectomy Revised July 10, 2019 * SURG.00045 Extracorporeal Shock Wave Therapy
Previous Title: Extracorporeal Shock Wave Therapy for Orthopedic Conditions
Revised
July 10, 2019 SURG.00120 Internal Rib Fixation Systems Revised September 4, 2019
GENE.00010 Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
Revised
Clinical UM Guidelines On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Amerigroup. These guidelines were adopted by the Medical Operations Committee for
Medicare Advantage members on July 5, 2019.
Publish date Clinical UM Guideline #
Clinical UM Guideline title New or revised
June 27, 2019 CG-SURG-97 Cardioverter Defibrillators New June 27, 2019 CG-DRUG-98 Bendamustine Hydrochloride Revised June 27, 2019 CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder
and Chronic Pain Revised
June 27, 2019 CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting Revised July 10, 2019 CG-SURG-100 Laser Trabeculoplasty and Laser Peripheral Iridotomy New July 10, 2019 CG-ADMIN-01 Clinical Utilization Management (UM) Guideline for Pre-Payment
Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
Revised
July 10, 2019 CG-ANC-06 Ambulance Services: Ground; Non-Emergent
Revised
July 10, 2019 CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy Revised July 10, 2019 CG-DME-07 Augmentative and Alternative Communication (AAC) Devices with
Digitized or Synthesized Speech Output Previous title: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
Revised
July 10, 2019 CG-DME-08 Infant Home Apnea Monitors Revised July 10, 2019 CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices Revised July 10, 2019 CG-DME-42 Non-implantable Insulin Infusion and Blood Glucose Monitoring
Devices Revised
July 10, 2019 CG-DME-45 Ultrasound Bone Growth Stimulation Revised July 10, 2019 CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the
Facility Setting Revised
July 10, 2019 CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
Revised
July 10, 2019 CG-MED-57 Cardiac Stress Testing with Electrocardiogram Revised July 10, 2019 CG-MED-59 Upper Gastrointestinal Endoscopy in Adults Revised
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Publish date Clinical UM Guideline #
Clinical UM Guideline title New or revised
July 10, 2019 CG-SURG-11 Surgical Treatment for Dupuytren's Contracture Revised July 10, 2019 CG-SURG-17 Trigger Point Injections Revised July 10, 2019 CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI) Revised July 10, 2019 CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for
Arterial Revascularization of the Lower Extremities Revised
July 10, 2019 CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants Revised July 10, 2019 CG-SURG-85 Hip Resurfacing Revised July 10, 2019 CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis
Access Circuit Dysfunction Revised
September 4, 2019 CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
New
September 4, 2019 CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
New
September 4, 2019 CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus New September 4, 2019 CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic
Cardiomyopathy New
AGPCRNL-0055-19
Clinical Laboratory Improvement Amendments for Amerigroup
Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment.
To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or
its electronic equivalent effective July 1, 2015. The CLIA certificate identification number must be submitted in one of the following manners:
Claim format and elements
CLIA number location options
Referring provider name and NPI number location options
Servicing laboratory physical location
CMS-1500 (formerly HCFA 1500)
Must be represented in field 23
Submit the referring provider name and NPI number in fields 17 and 17b, respectively.
Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the address is not equal to the bil ling provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23.
HIPAA 5010 837 Professional
Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01
Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.
Physical address of servicing provider must be represented in the 2310C loop if not equal to the bil ling provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02.
Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure
accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form in order for the procedure to be evaluated to determine eligibility for benefit coverage.
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Laboratory procedures are only covered and, therefore, payable i f rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the
particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code and/or does not have complete servicing provider demographic information will be considered incomplete and
rejected or denied beginning November 1, 2019. If you have additional questions, you can contact Provider Services at the number on the back
of the member ID card.
AGPCRNL-0049-19
Special section: Long-Term Services and Supports (LTSS)
LTSS Provider Claims Corner Page 29
Employment and Community First CHOICES upcoming employment training
Page 29
Disability Mentoring Day announcement Page 30 People with disabilities now eligible for Internet Essentials from Comcast
Page 30
Amerigroup Foundation partners with Chattanooga-area organization for Adaptive Water Sports Day
Page 31
Electronic visit verification system reminder
Page 32
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LTSS Provider Claims Corner
As a reminder, providers must revalidate their Medicaid IDs with the Division of TennCare’s provider data management system every three years or as changes to the organization occur. Failure to revalidate your Medicaid ID can result in a denial of claims with the denial reason of
No Medicaid # and/or Disclosure Form. If you have any questions related to revalidating or updating your Medicaid ID, please contact [email protected] or your assigned Provider Relations representative.
A common reason for denial that we see is Resubmit with Valid Procedure/Revenue Code. It is best practice to always bill with your authorization and rate sheet close by. When submitting claims in Availity, some services have unique modifiers that must be listed in order following
the main procedure code. The TennCare CHOICES and Employment and Community First CHOICES rate sheets include the procedure code with modifiers, if applicable, and the revenue code. If you need a copy of a rate sheet, please reach out to your assigned Provider Relations
representative.
TN-NB-0218-19
Employment and Community First CHOICES upcoming employment training
West region Middle region East region
November 5, 2019 9 a.m.-2 p.m. Central time 7130 Goodlett Farms Parkway,
Suite 107 Memphis, TN 38016
November 6, 2019 9 a.m.-2 p.m. Central time 22 Century Blvd.,
Third Floor Cumberland Nashville, TN 37214
November 7, 2019 9 a.m.-2 p.m. Central time 9041 Executive Park Drive, Suite
250 Knoxville, TN 37923
Employment and Community First CHOICES (ECF CHOICES) agenda
9 a.m.-11:30 a.m. ECF CHOICES employment 101 o This session will include a review of the ECF CHOICES employment philosophy,
ECF CHOICES employment services definitions, outcome based services process, documentation requirements and employment training requirements.
Note: New ECF CHOICES employment staff (job coaches and job developers) will be given priority.
11:30 a.m.-12:30 p.m. Networking lunch o This session will include a meet and greet with ECF CHOICES providers, your
Provider Relations team and employment specialists.
12:30 p.m.-2 p.m. ECF CHOICES employment success in CLS o This session will include an overview of ECF CHOICES employment services and
tips on how to best support individuals in community living supports (CLS) so
they can obtain/maintain employment and coordinate with ECF CHOICES employment providers. Note: This session is only for CLS staff and direct support personnel.
TN-NB-0218-19
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Disability Mentoring Day announcement
Amerigroup Community Care is excited to be a Disability Mentoring Day (DMD) 2019 host. October is Disability Employment Awareness Month, and DMD activities will take place throughout the month. The theme for this year is The Right Talent, Right Now, and we will be
hosting mentees in all three grand regions — East, Middle and West. DMD is designed to bring individuals with disabilities into the workplace where they learn about
various career opportunities within a host site. This event aligns perfectly with our commitment to our Project SEARCH program; we might even be able to identify potential interns for next year’s program.
The mentees will get to spend some one-on-one time with their mentor in an area of their interest, overseeing a typical workday, identifying necessary skills and learning about possible employment prospects. This will provide the mentees a valuable opportunity for career
exploration and give them a chance to learn what it is like to work in an administrative environment, such as Amerigroup.
To learn more about DMD, follow the link below to the American Association of People with Disabilities website: https://www.aapd.com/disability-mentoring-day.
For any additional information, you can also contact Tina Jones via email at [email protected] or by phone at 865-214-0765.
TN-NB-0218-19
People with disabilities now eligible for Internet Essentials from Comcast
In its ongoing effort to close the digital divide, Comcast is expanding its discounted broadband service to include all households with people with disabilities. The expansion is the biggest of 11 program expansions announced in the eight-year history of the Internet Essentials program, launched in 2011 by Comcast to help win approval of the U.S. Federal Communications
Commission of its merger with NBC Universal. Comcast's Internet Essentials provides internet service to qualified househol ds for only $9.95 a
month, plus the option of buying an internet-ready computer for less than $150. The program is already the largest broadband adoption program of its kind in the United States, with connections to eight million low-income Americans, including 27,000 persons in the
Chattanooga area. The company estimates that more than three million additional low-income households, including households with people with disabilities, are now eligible to apply with the latest program addition. "This expansion is the culmination of an audacious goal we set
eight years ago, which was to meaningfully and significantly close the digital divide for low -income Americans," said David L. Cohen, senior executive vice president and chief diversity officer of Comcast NBC Universal. "The internet is arguably the most important technological
Page 32 of 35
innovation in history, and it is unacceptable that we live in a country where millions of families and individuals are missing out on this life-changing resource,” he added.
According to U.S. Census data, households in cities with the highest poverty rates are up to ten times more likely than those in higher earning communities not to have fixed broadband at home. Cohen said the most significant barrier to broadband adoption in low-income
communities remains a basket of digital literacy deficits, lack of digital awareness and a fear of the internet. As a result, since 2011, Comcast has also invested more than $650 million to support digital literacy training and awareness programs, including its support for Tech Goes
Home in Chattanooga. Comcast has either sold or donated more than 100,000 discounted and heavily subsidized computers to families and veterans that need one. "Whether the internet is used for students to do their homework, adults to look for and apply for new jobs, seniors to
keep in touch with friends and family, or veterans to access their well -deserved benefits or medical assistance, it is absolutely essential to be connected in our modern, digital age," Cohen said.
To be eligible to apply to the program, low-income applicants simply need to show they are participating in one of more than a dozen different federal assistance programs. Those eligible for Internet Essentials include anyone on Medicaid, Supplemental Nutriti on Assistance Program
(SNAP) or food stamps, or Supplemental Security Income. Comcast already accepts applications from households that meet the following criteria:
A student eligible to participate in the National School Lunch Program
Persons who live in public housing or receive Housing and Urban Development Housing Assistance, including Section 8 vouchers
Persons who participate in the Veterans Pension Program
Low-income seniors and community college students in select pilot markets For more information or to apply for the program in one of seven different languages, please
visit https://www.internetessentials.com, call 1-855-846-8376, or contact Dave Flessner at [email protected] or at 423-757-6340. Spanish-only speakers can also call 1-855-765-6995.
TN-NB-0218-19
Amerigroup Foundation partners with Chattanooga-area organization for Adaptive Water Sports Day The Amerigroup Foundation, in partnership with Disabled Sports USA, provided a financial
sponsorship to Sports, Arts and Recreation of Chattanooga (SPARC) to benefit their Adaptive Water Sports Day. With the help of some
dedicated volunteers, 39 individuals with physical and intellectual disabilities were able to get out into the water and enjoy a wide range of activities, including water skiing,
tubing, paddle-boarding, fishing and boating. In
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years past, participants had to take turns as equipment availability was limited, but thanks to the Amerigroup Foundation’s gift, SPARC was able to purchase additional equipment and participants were able to spend more time on the lake. “Our work is to build healthier lives and
healthier communities. Partnering with organizations like SPARC and Disabled Sports USA allows us to get involved and do just that,” Kraig Dalton, chief operating officer of Amerigroup Community Care, said about the event.
TN-NB-0218-19
Electronic visit verification system reminder
The electronic visit verification (EVV) system is an automated electronic system used to monitor member receipt and utilization of TennCare CHOICES home- and community-based services (HCBS). Provider staff arrival and departure are captured through the use of a static GPS device
in EVV. The system acts as verification that services are being performed within the member’s preferred schedule, approved location and may also be used by the provider for submission of claims. Our current EVV vendor is Healthstar.
To use the EVV system, providers promptly check in using a GPS tablet device upon arri val at the individual’s home. The provider’s employee may download the EVV application to their own Android or Apple smartphone at no charge; this can then be used for checking in and out of a
visit if the individual’s tablet is not available. This confirms the identity of the provider/staff worker, as well as the arrival time and location. If neither of these options are available, the caregiver can use the individual’s phone to check in.
At the end of the shift or assignment (and prior to leaving the individual’s home), the provider/staff worker will check out using the tablet device or the same method in which the
check-in occurred, logging the departure time and completing a brief survey. This survey will only be available via the tablet method for checking out. If a provider/staff worker fails to check in at the appropriate time, the EVV system will alert
Amerigroup Community Care, and steps will be taken to ensure the individual receives the appropriate care at the appropriate time.
At a minimum, if an individual is scheduled to receive care, providers should have at least one full-time staff person devoted to EVV system monitoring (including after hours and weekends) and two staff persons fully trained and knowledgeable of the EVV system and its functionality.
Use of this system is compulsory for providers administering HCBS to Amerigroup members. Providers are responsible for complying with the following EVV system processes:
Log the arrival and departure of the provider/staff worker.
Verify that services are being delivered at the correct location (e.g., the individual’s home) and at the appropriate time.
Verify the identity of the provider/staff worker providing the service to the individual.
Match the services provided to an individual with the services authorized in the person-centered support plan.
Ensure adherence to the established schedule of services.
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Ensure the provider/staff worker delivering the service is authorized to deliver such services.
Establish a schedule of service delivery with as much flexibility and/or specificity within the authorization and program rules as the individual wants and needs.
Identify the time each service is needed, including the amount, frequency, duration and scope of each service.
Provide notification to the EVV team if a worker does not arrive as scheduled or otherwise deviates from the authorized schedule; this ensures service gaps and the
reason service was not provided as scheduled are identified and addressed immediately and that backup plans are implemented as appropriate.
Keep the late/missed visit (LMV) dashboard up-to-date and accurate; visibility of LMV entries is lost from the dashboard after seven calendar days, and this information is
used for a state report and must be accurate.
Log the delivery of home-delivered meals, including the individual’s name, time delivered and, if applicable, the reason a meal was not delivered.
Generate claims for submission to Amerigroup.
Capture worker/individual surveys.
Manage all tablets assigned to individuals under their care. Amerigroup requires contracted providers to use the EVV system for applicable services. Contracted providers must have at least two staff persons fully trained on the EVV system who
can train caregivers on using the device in the individual’s home. An additional expectation is that at least one staff person with the contracted provider is dedicated to monitoring caregiver activity to ensure caregivers are in the individual’s home providing services at the scheduled
time agreed upon when the referral was accepted. It is imperative providers comply with these standards to ensure individuals are receiving services in a timely manner. To maintain acceptable compliance scores, it is required that 90
percent or more of scheduled services submitted for payment have GPS coordinates attached. Provider compliance with appointment staffing will be monitored on an ongoing basis. Providers are required to submit individual specific, late and missed information to the MCO for
TennCare monthly reporting. Providers that have not met the minimum performance requirements are subject to a corrective action plan (CAP), to include a moratorium on new referrals and imposition of financial sanctions (pass through liquidated damages). Continued
noncompliance after the completion of a CAP may result in reinstatement of the CAP or additional action, including, and up to, termination.
TN-NB-0218-19
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Reimbursement Policies: Policy Update
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (Policy 06-0149, effective 01/01/19)
Currently, Amerigroup Community Care includes Early and Periodic Screening, Diagnosis and Treatment (EPSDT) component services in the reimbursement of preventive medicine evaluation and management (E&M) visits unless they are appended with Modifier 25 to indicate a significant, separately identifiable E&M service by the same physician on the same
date of service. However, effective January 1, 2019, the following EPSDT component services will be separately
reimbursable from the preventive medicine E&M visit:
Hearing screening with or without the use of an audiometer or other electronic device
Vision screening
For additional information, refer to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) reimbursement policy at https://providers.amerigroup.com/TN.
TN-NB-0192-19 New Policy: Update
Drug Screen Testing (Policy 19-001, effective 11/01/19) The effective date of this policy has been updated from 10/1/19. Amerigroup Community Care allows separate reimbursement for definitive drug testing of 1-7 drug classes. Effective November 1, 2019, definitive drug testing for eight or more drug classes
will not be separately reimbursed when performed on the same date of service as presumptive testing.
Definitive drug testing may be done to confirm the results of a negative presumptive test or to identify substances when there is no presumptive test available. Provider’s documentation and member’s medical records should reflect that the test was properly ordered and support that
the order was based on the result of the presumptive test. In the event a reference lab (POS = 81) performs both presumptive and definitive tests on the same date of service, records should reflect that the ordering/treating provider issued a
subsequent order for definitive testing based on the results of the presumptive tests. For additional information, refer to the Drug Screen Testing reimbursement policy at
https://providers.amerigroup.com/TN.
TN-NB-0161-19-A
