NaviNet You asked, we listened!

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1 The Newsletter for AmeriHealth Mercy Health Plan Providers Visit us on the web at Issue 1, 2012 In This Issue Shared Decision Making Collaborative Physician-Patient Communication...2 HealthChoices Expands in the Lehigh-Capital Zone...3 New Informal Provider Disputes Mailing Address...3 Dental Benefit Changes for Adult Members...4 The Importance of Hib Vaccine....4 News You Can Use NDC-HCPCS (J-code) Cross Walk - Obstetrical Needs Assessment Form (OBNAF) - Have you visited the Provider Center lately? Tips for Providing Culturally and Linguistically Appropriate Services....6 JIVA...8 INSERT: HEDIS Coding Guidelines NaviNet You asked, we listened! Have you noticed that the referral submission transaction is faster and easier to use? Many of our offices asked for improvements to this process and the following change was made in January: NaviNet now automatically creates a list of your offices frequently referred to provider groups so you will no longer have to search for them. The creation of this list began as your office started creating referrals on January 27th and is dynamically updated. You are still able to search for groups not in this list. We also continue to add care gap alerts that notify you of missing critical services that our members need to maintain good health. Recently added alerts that you will see when checking a member s eligibility and benefits or through the Reports Inquiry or Member Clinical Summary are: EPSDT eligible members that are missing vision, hearing and/or developmental screenings; Pharmacy alerts* for members with a recent history of an acute coronary syndrome not meeting AHA/ACC guidelines for secondary prevention; and Members with diabetes who have not filled test strips and lancets in the past 4 months. * All pharmacy care gaps are provided for informational purposes and require no reporting on your part. We are here to help you with the management of these services. After your intervention, if a member continues to be non-compliant i.e., not filling prescribed medications or keeping appointments with specialists, please do not hesitate to contact the AmeriHealth Mercy Rapid Response Outreach Team ( option 2) for assistance and outreach to that individual. Finally, there are Gaps in Care resources and tools on the Provider Center at NaviNet Care Gaps that you might find useful such as: The 2012 Gaps in Care Schedule Gaps in Care Specification Documents Pharmacy Gaps in Care Specification Documents We will continue to enhance the services and functions on NaviNet and welcome your suggestions for improvements at provider.communications@amerihealthmercyhp.com Questions? Visit our web site at 1

2 Shared Decision Making Collaborative Physician-Patient Communication The key to success in shared decision making is encouraging patients to take an active and engaged role in their health care in order to become well informed and to participate fully in deciding how they are going to manage their health conditions. Patient Education Initiative To support and improve shared decision making, Ameri- Health Mercy started our Ask Me 3 campaign. This campaign was the first step in working towards encouraging a collaborative relationship between AmeriHealth Mercy members and their physicians. The campaign is based on three questions patients need to ask you: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? For member education these Ask Me 3 questions have appeared in articles in the member newsletter, in a mass distributed pamphlet called Prepare for your Doctor s Visit and a laminated notification card to be posted in your exam room (if you would like copies of these materials, please contact your Provider Contracting Representative). We will continue to reinforce this message throughout 2012 to encourage our members to take a partnership role in their care, share more information with you during office visits and be vested in complying with a mutually agreed upon treatment plan. Physician Communication Tips To move closer toward this participatory style of care, we ask you to encourage adult interactions, keep conversations at the patient s level of understanding and let the patient do most of the talking. According to an article from Family Practice Management, Improving Patient Communication in No Time, it is possible to be an effective communicator in an environment where the average patient visit lasts only 15 minutes. Here are some tips from the article: Don t omit the pleasantries: One thing that s very important is how you enter a room. Even with time at a premium, walk into the exam room with a smile, shake the patient s hand (if culturally appropriate), call the patient by name (first name or surname, whichever the patient prefers), and sit down. Sitting down places the doctor at eye level or below eye level, this relaxes the patient so that he or she will communicate more openly. Relate with your eyes: Really look into the patient s eyes. Avoid focusing on a computer screen, writing down information or reading a chart. Patients often perceive they have spent more time with you when an eye connection is made. Listen without interrupting: Studies show that a patient normally speaks for an average of 18 seconds before the physician interrupts, however if patients are allowed to talk for three to four minutes, they tell about 90 percent of what is wrong with them. Patient satisfaction is improved when they feel that their physician has listened to and heard their concerns. Keep conversations on track: Helping patients stay on track is key to increasing efficiency and maximizing the value of the time you have with them. Don t appear rushed, even if you are: Avoid two nonverbal behaviors: looking at your watch and keeping one hand on the doorknob. Focus your attention on the patient and stop yourself from being preoccupied. To read the entire article, Improving Patient Communication in No Time, go to: 2 Questions? Call Provider Services at

3 HealthChoices Expands in the Lehigh-Capital Zone On July 1, 2012, Franklin, Fulton and Huntingdon counties will join the existing HealthChoices Lehigh-Capital Zone. The ACCESS Plus Program will end in these counties on June 30, To service Medical Assistance consumers eligible for HealthChoices Physical Health Managed Care or currently enrolled in the ACCESS Plus Program, providers will need to join one of five HealthChoices Managed Care Organizations (MCOs). Open enrollment for consumers currently in the ACCESS Plus Program will begin May, When consumers do not choose a managed care organization during open enrollment, they will be auto-assigned to one of the five MCOs. We look forward to adding providers in these three counties to the AmeriHealth Mercy network. We know you have a choice in the managed care network you choose to work with. AmeriHealth Mercy is proud to be a plan that consistently meets or exceeds the expectations of its providers and members. If you have any questions regarding this expansion, please contact your Provider Contracting Representative or Provider Services at New Informal Provider Disputes Mailing Address To assist in expediting the informal dispute process, AmeriHealth Mercy has established a new Post Office Box for Informal Provider Disputes. Informal Disputes are generally administrative in nature and do not include decisions concerning medical necessity. Effective April 1, 2012, please mail all Informal Provider Disputes to: AmeriHealth Mercy Health Plan Informal Disputes P.O. Box 7329 London, KY *** Please clearly indicate Informal Provider Dispute at the top of the request. *** Continue to send Provider Appeals (written requests for the reversal of a medical denial) to: Inpatient Appeals Outpatient Appeals AmeriHealth Mercy Health Plan AmeriHealth Mercy Health Plan Provider Appeals Department Provider Appeals Department P.O. Box 7307 P.O. Box 7316 London, KY London, KY Any questions, please contact your Provider Contracting Representative, or AmeriHealth Mercy Provider Services at Questions? Visit our web site at 3

4 Dental Benefit Changes for Adult Members As of January 8, 2012, AmeriHealth Mercy members age 21 and over have changes in their dental benefits. These changes do not apply if the member is under the age of 21 or if the member is over 21 years of age and resides in a long term care facility, or intermediate care facility. However, all current prior authorization policies, parameters and criteria will remain in place. Adults can get one dental exam and one cleaning per provider every 180 days. Therapeutic pulpotomies will be covered for adults age 21 and older. Pulpotomy is the removal of a portion of the pulp with the aim of maintaining the vitality of the remaining portion by means of an adequate dressing. It may be performed on primary or permanent teeth; is not to be construed as the first stage of a root canal, and may be used to provide symptomatic relief of dental pain. Coverage for re-cementing of crowns. Once per lifetime, adult members are eligible for: Dentures: one removable prosthesis per member, per arch, regardless of type (full/partial) If the member received a partial or full upper denture since March 1, 2004, paid by AmeriHealth Mercy, other MCO s, or the state s fee-for- service plan, he/ she may be able to get another partial or full upper denture. Additional dentures will require a benefit limit exception. If the member received a partial or full lower denture since March 1, 2004, paid by AmeriHealth Mercy, other MCO s, or the state s fee-for-service plan, he/ she may be able to get another partial or full lower denture. Additional dentures will require a benefit limit exception. Adult Members may be eligible to receive the following services with a benefit limit exception: Crowns and related services Root canals and other endodontic services Periodontal services Additional cleanings and exams If you have any questions about these benefit changes, contact AmeriHealth Mercy Provider Services at The Importance of the Hib Vaccine Before Hib vaccines, there were approximately 20,000 cases of invasive Hib disease each year in the United States. Prior to its availability, Hib was the most common cause of bacterial meningitis. About 12,000 children each year most of them younger than 5 years of age got Hib meningitis. All infants older than six weeks and under five years of age should receive the Hib vaccine. Please be sure to immunize your pediatric patients against this very serious infection, following these recommended ages: 2 months 4 months 6 months (not needed if the PedvaxHIB or ComVax brand of vaccine was given at 2 and 4 months) Between 12 and 15 months For a complete immunization schedule for children aged 0 6 yrs. visit the EPSDT section of the Provider Center at NDC-HCPCS (J-code) Cross Walk Claims for office administered medications must be submitted with both J-code and NDC information. To aid you in submitting this required information, we have provided a direct link to the CMS NDC-HCPCS cross walk in the Billing Information section of the Provider Center at As a reminder, please include the N4 qualifier, 11 digit NDC, Drug Name, NDC Unit Qualifier (UN,ML, GR,or F2), and NDC quantity on your claims to minimize denials. 4 Questions? Call Provider Services at

5 News You Can Use Obstetrical Needs Assessment Form (OBNAF) The Department of Public Welfare has revised the Obstetrical Needs Assessment Form (OBNAF) that is used by all Lehigh-Capital Health Choices managed care organizations. The form is available on under Provider Forms and should be faxed to our WeeCare Department at Within 48 hours of the initial prenatal visit: Complete the top portion; Past OB complications, Current Risks, Active Medical/Mental Health Conditions and Social, Economic and Lifestyle sections. The week visit: Update all areas as needed, adding dates of prenatal visit to date. Postpartum visit: Add postpartum information with date of service and any additional visit dates as needed. New risk factors identified should be indicated on the form and faxed at any time during pregnancy. If you have any questions call Provider Services at or your Provider Contracting Representative. Have you visited the Provider Center lately? AmeriHealth Mercy s latest news, information and resources are easily accessible by visiting the Provider Center of our website ( The following are examples of the wealth of information available to you on this user-friendly site. We invite you to visit our provider website often. Please feel free to contact us at provider.communications@amerihealthmercyhp.com if there is anything you would like added to the center. Clinical Information Clinical Practice Guidelines (hard copies of any of the Clinical Practice Guidelines are also available by calling Provider Services at ) EPSDT information Current periodicity schedule and immunization tables Direct links and contact information to the Vaccines for Children Program Member Information Member Rights and Responsibilities Co-pay Schedule, Behavioral Health and Medical Assistance Transportation Program (MATP) contact numbers Eligibility Verification Guide Direct links to secure services NaviNet JIVA Web-based service for prior authorization request submission MedSolutions Outpatient radiology authorization Council for Affordable Quality Healthcare (CAQH) for credentialing AmeriHealth Mercy Dental Program Reference Materials Provider Directory Provider Manual Drug Formulary Billing Information Questions? Visit our web site at 5

6 Tips for Providing Culturally and Linguistically Appropriate Services This is the second of a three article series providing tips and strategies for communicating with members with diverse backgrounds, both culturally and linguistically. This issue will focus on caring for members of the Vietnamese culture. The Vietnamese people are a significant part of the fastest growing ethnic group in the United States, the Asian American. As of 2009, there were more than 1.1 million immigrants of Vietnamese descent, making them the fifth largest immigrant group. They are estimated to become the second largest Asian American group in the country by Despite these large numbers and projections, the Vietnamese patientdoctor relationship has been understudied. Here are some tips and observations from the University of Washington s Medical Center s Culture Clues that can assist you in communicating with and treating your Vietnamese patients. What Are the Vietnamese Culture s Norms about Touch? Understanding Personal Space, Eye Contact and Body Language Handshakes are appropriate between men. Women do not shake hands. Respect is shown to authority figures by giving a gentle bow and avoiding eye contact. Some elder or new immigrant patients may consider the head sacred. Avoid touching it unless necessary. If an exam or procedure requires head care, let your patient know in advance. Your patient may nod, smile, and/or say yes or ya to acknowledge he/she heard you, rather than that he/she understands or approves. Ask open-ended questions to verify understanding and encourage them to ask questions. Your patient may be reluctant to say no to a doctor or health care provider because it may be considered disrespectful. Understanding Norms about Touch and Modesty Consider the modesty of women and girls when giving a pelvic exam. Many young nulliparous women are modest about having an exam and may prefer a female doctor to do it. Before you begin a gynecological exam, it is important to ask your patient May I examine you? Ask your patient if she prefers a female doctor, attendant, or interpreter to remain in the room during the exam. Helping Patients Become Compliant Building Bridges between Folk Remedies and Western Health Care Many patients will get their care from folk healers first, and will seek western medical care if the folk treatments fail. As a result, patients may present at your office acutely ill. There are a variety of common folk remedies that your patient may use, including cao gio (coin rubbing) or bat gio (skin pinching). These remedies are used to allow unwanted winds or elements to escape the body. They are not harmful, and many patients report feeling better afterwards. Build bridges between folk medicine and western care. When considering folk practices, determine when the remedies are beneficial, neutral, or harmful. Incorporate beneficial and neutral remedies into the plan of care. Consider potential drug interactions. 6 Questions? Call Provider Services at

7 Explaining the Causes of Illness and Disease Your patient may see illness as an imbalance between body and nature (ying and yang, male and female, dark and light) and folk cures for these imbalances are expressed as hot and cold. Provide prompt communication about test results. Vietnamese patients are uncomfortable with invasive laboratory or diagnostic tests and may lose faith in their providers if results are not communicated immediately. Understanding the Meaning of a Hospital Stay or Surgery Your patient may see the hospital stay or surgery as the last resort before death. A visit from a clergy member may also be perceived as a death-bed visit. If possible, perform outpatient procedures or ensure understanding of why a hospital stay is necessary. Check with your patient or family member before a member of the clergy visits your patient. How Are Medical Decisions Made in the Vietnamese Culture? Making Decisions about Health Care Consult with the family in cases of serious or terminal illness. The family may want to make the health care decisions to avoid worrying the patient. The family spokesperson is often the person with the best command of the English language. Women act as primary providers at the bedside although the entire family may care for the hospitalized patient. Ask your patient whom he/she wants included in the medical decisions. Be aware of the importance of family members serving in caregiver roles and consider extending visiting hours. If your patient doesn t want to make decisions for him/ herself, let them know they need to prepare a Durable Power of Attorney for health care. Language Services Associates (LSA) offers Ameri- Health Mercy providers the opportunity to contract with them for discounted interpreter service rates. Contact LSA at , extension for complete details. Questions? Visit our web site at

8 IMPORTANT REMINDER: JIVA is the New Web-based Service for Submission of Prior Authorization and Admissions Requests (Requests submitted via iexchange will be available for viewing until April 30, 2012) Prior authorization and admission-related functions are now submitted via JIVA through a single log-in to Ameri- Health Mercy s Plan Central page on NaviNet. Services available through JIVA are: Requests for prior authorization Requests for inpatient, outpatient, home care and DME services Submission of requests for extension of services Verification of elective admission authorization status You can find the JIVA Provider Training Presentation, Job Aids and Frequently Asked Questions on the AmeriHealth Mercy Plan Central Page of NaviNet, as well as the dedicated JIVA section of AmeriHealth Mercy s Provider Center If you are not already a NaviNet user, it is very simple to start the process! Log on to to register, or call to speak to NaviNet Customer Service. 200 Stevens Drive Philadelphia, PA Messenger Editiorial Board Eric J. Berman, DO, MS Chief Medical Officer, Northeast Region, AmeriHealth Mercy Health Plan Marge Angello, RN Executive Director Steve Orndorff Associate Vice President Provider and Community Affairs Linda Travaglione Director, Provider Communications Marianne Gravina Editor, Provider Communications Matt Reilly Contributor, Provider Communications Questions? Call Provider Services at

9 2012 HEDIS Coding Guidelines Effectiveness of Care - Prevention Measure and Coding Directions Requirement CPT HCPCS UB Revenue Adult BMI Assessment (ABA) , , , , , , , 99411, 99412, 051x, , , G0344, G , 99429, 99455, x, 0982, 0983 (Code the visit + a BMI code) BMI V85.0-V85.5 Requirement CPT HCPCS UB Revenue Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (WCC) (Code the Visit + each appropriate component) Childhood Immunization Status (CIS) Immunizations for Adolescents (IMA) , , , , , , , , , 99411, 99412, 99420, 99429, 99455, BMI Percentile Counseling for Nutrition S9470, S9452, S9449, G0270-G0271 Counseling for Physical Activity S9451 Requirement CPT ICD-9-CM Diag/Proc HCPCS DTaP 90698, 90700, 90721, IPV 90698, 90713, MMR 90707, Measles and rubella Measles ; Mumps ; Rubella ; Hib , 90698, 90721, Hepatitis B 90723, 90740, 90744, 90747, , 070.3, V02.61 G0010 VZV 90710, , 053 Pneumococcal conjugate G0009 Hepatitis A , Rotavirus (2 dose) Rotavirus (3 dose) Influenza 90655, 90657, 90661, G0008 Meningococcal 90733, Tdap Td 90714, Tetnus Diptheria Human Papillomavirus Vaccine for Female Adolescents (HPV) HPV 90649, Breast Cancer Screening (BCS) Requirement CPT HCPCS UB Revenue Mammography G0202, G0204, G , 0403 Cervical Cancer Screening (CCS) Cervical Cancer Screening , 88147, 88148, 88150, , , 88174, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q Lead Screening Children (LSC) Requirement CPT Lead Tests Requirement CPT ICD-9-CM Diag/Proc UB Revenue Appropriate Treatment for Children With Upper Respiratory Infection (URI) (Code the visit + URI assosciated diagnosis) Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) (Code the visit + bronchitis assosciated diagnosis) , , , , , , , 99411, 99412, 99420, , , , , 99385, 99386, 99395, 99396, , 99411, 99412, 99420, , x, , , 0982, x, , , 0982, x, , , 0982, 0983

10 Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) (Code the visit + COPD assosciated diagnosis) Spirometry Testing 94010, , 94060, 94070, 94375, , 492, x, , , 057x-059x, 082x-085x, 088x, 0982, 0983 Use of Appropriate Medications for People With Asthma (ASM) (Code the visit + Asthma assosciated diagnosis) , , , , , , , , , 99411, 99412, 99420, x, , , 077x, 0982, 0983 Requirement CPT PTCA , , , , 92982, Cholesterol Management for Patients With Cardiovascular Conditions (CMC) IVD Requirement CPT (Code the Visit + each appropriate component) LDL Screening 80061, 83700, 83701, 83704, Requirement CPT UB Revenue Outpatient , , , , , , , , , 99411, 99412, 99420, 99429, 99455, x, , , 057x-059x, 077x, 0982, 0983 Requirement ICD-9-CM Diag/Proc Controlling High Blood Pressure (CBP) Hypertension 401 (Code the visit + Hypertention Diagnosis) Requirement CPT UB Revenue Outpatient visits , , , , EFFECTIVENESS OF CARE - DIABETES Measure and Coding Directions Requirement ICD-9-CM Diag/Proc Diabetes 250, 357.2, 362.0, , Requirement CPT UB Revenue Comprehensive Diabetes Care (CDC) (Code the Visit + Diabetes Diagnosis + Each Appropriate Component) 92002, 92004, 92012, 92014, , , , , , , , , , 99411, 99412, 99420, 99429, 99455, Requirement CPT A1C Test 83036, LDL-C Screening 80061, 83700, 83701, 83704, Nephropathy screening test 82042, 82043, 82044, x, , , 057x-059x, 082x-085x, 088x, 0982, 0983 USE OF SERVICES Measure and Coding Directions Requirement CPT HCPCS ICD-9-CM Diag/Proc Well-Child Visits in the First V20.2, V20.3 V70.0, V70.3, Well Child visits 99381, 99382, 99391, 99392, 99432, G0438, G Months of Life (W15) V70.5, V70.6, V70.8, V70.9 Well-Child Visits in the Third, Fourth, Fifth V20.2, V70.0, V70.3, V70.5, Well Child visits 99382, 99383, 99392, G0438, G0439 and Sixth Years of Life (W34) V70.6, V70.8, V70.9 Adolescent Well-Care Visits (AWC) Well Child visits , G0438, G0439 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ACCESS-AVAILABILITY OF CARE Option 1: Any prenatal care visit to an OB practitioner, a midwife or family practitioner or other PCP with documentation of when prenatal care was initiated. Prenatal and Postpartum Care (PPC) (One of the 4 options has to occur) Option 2: Any visit to an OB practitioner or midwife with one of the following: Option 3: Any visit to a family practitioner or other PCP with a pregnancy related ICD-9-CM Diagnosis code AND one of the following: * When using a visit to a family practitioner or other PCP, it is necessary to determine that prenatal care was rendered and that the member was not merely diagnosed as pregnant and referred to another practitioner for prenatal care. Option 4: Any visit to a family practitioner or other PCP with diagnosis-based evidence of prenatal care in the form of a documented LMP or EDD with either a completed obstetric history or risk assessment and counseling/education.