Provider Quick Reference Card

Transcription

1 PODIATRY The benefit excludes routine hygienic care of the feet in the absence of a pathological condition. No precertification is required for coverage of E&M testing and most procedures when provided by a participating podiatrist. Visit to look up specific RADIATION THERAPY No precertification is required for coverage of radiation therapy procedures when performed in the following outpatient settings by a participating facility or provider: office, outpatient hospital and ambulatory surgery center. is required for coverage of services rendered in an inpatient setting. RADIOLOGY See Diagnostic Testing. REHABILITATION THERAPY (OUTPATIENT: OCCUPATIONAL THERAPY, PHYSICAL THERAPY AND SPEECH THERAPY) Medicaid and NJ FamilyCare A: Outpatient therapy services are covered by New Jersey Medicaid FFS. NJ FamilyCare B and C: Outpatient therapy services are covered by New Jersey Medicaid FFS for 60 days of therapy per year. NJ FamilyCare D: Outpatient physical therapy, occupational therapy and speech therapy services for nonchronic conditions, acute illness and injuries are covered under New Jersey Medicaid FFS. SKILLED NURSING FACILITY Skilled-nursing care is limited to the first 30 days of admission to a nursing facility. Covered benefits are limited to rehabilitation services for NJ FamilyCare B, C and D enrollees. is required for coverage of all care and services provided in a skilled-nursing facility. SLEEP STUDY is required. STERILIZATION Sterilization is a covered benefit for members age 21 and older. No precertification or notification is required for sterilization procedures, including tubal ligation and vasectomy. The sterilization consent form is required for claims submission for primary sterilization procedures. Reversal of sterilization is not a covered benefit. Sterilization services from a nonparticipating provider are not covered. TERMINATION OF PREGNANCY Elective, induced abortion and related services are covered by the New Jersey Medicaid FFS program. For benefit questions, members may call the New Jersey Medicaid Hotline at For New Jersey Medicaid FFS claims information, providers should call UNISYS at TRANSPORTATION For all cities and counties, members are directed to the County Board of Social Services or Logisticare at NJ FamilyCare B, C and D members are ineligible for routine transportation generally. NJ FamilyCare D: Coverage is limited to ambulance services for medical emergencies only. Transportation related to emergency room visits does not require precertification. Medicaid and NJ FamilyCare A, B and C: Medically necessary transportation (ambulance, medical intensive care units and invalid coach) is covered for any managed care or nonmanaged care covered benefit. The contractor shall make lower mode transportation services available to any enrollee requesting transportation to a nonhospital service provider when the nonhospital service provider is located greater than 30 miles from the enrollee s residence and whenever the contractor does not have a network/alternative provider of medically necessary covered services closer to the enrollee s home. Medicaid and all NJ FamilyCare Members: Lower-mode transportation is available to any member requesting transportation to any provider for a medically necessary covered benefit if the location is greater than 30 miles from the member s residence when there is no closer network provider available. AMERIGROUP PROVIDER SERVICES automated member eligibility, health education materials, outreach and more to providers. Please note the following definitions: PRECERTIFICATION VISION CARE (MEDICAL) No precertification is required for testing and procedures. is required for repair of eyelid defects. Services considered cosmetic in nature are not covered. VISION CARE (ROUTINE) NJ FamilyCare A, B and C: Coverage is limited to one routine eye exam per year. Members may contact Block Vision at eyeglass lenses once every 12 months for members under age 19 and age 60 and older. eyeglass lenses once every 24 months for members age 19 through 59 as medically necessary. NJ FamilyCare D: Members are eligible for a new pair of eyeglass lenses every 24 months or as medically necessary. Coverage is provided for contact lenses once every 24 months for specific pathological conditions and vision correction that cannot be improved to at least 20/70 or better with regular lenses. Members not meeting the medical necessity benefit can opt for contact lenses as a value-added benefit. Amerigroup will reimburse the lesser of usual and customary charges or $100. Provider Quick Reference Card REVENUE CODES To the extent the following services are covered benefits, precertification or notification is required for all services billed with the following revenue codes: All inpatient and behavioral health accommodations 0023 Home health prospective payment system 0240 through 0249 All-inclusive ancillary psychiatric 0632 Pharmacy multiple source 3101 through 3109 Adult day care and foster care AMERIGROUP ELECTRONIC DATA INTERCHANGE AT For more precertification/notification requirements on Amerigroup services, visit us online and click on Lookup Tool. Results of telephone or faxed precertification/notification requests will be provided by phone or fax within two business days. Note: Behavioral health information may be faxed to AMERIGROUP WEB SITE AND PROVIDER INQUIRY LINE AVAILABLE 24 HOURS A DAY, 7 DAYS A WEEK Amerigroup now provides an online resource designed to significantly reduce the time your office spends on eligibility verification, claims status and precertification/notification. Visit us at For those times when you can t access the Internet, you may receive claims, eligibility and precertification/notification over the telephone by calling Simply say your national provider identifier when prompted by the recorded voice. It s easy! The recording guides you through a menu of options, allowing you to select the information or materials you need. Well-woman exams are covered once per calendar year when performed by a PCP or in-network gynecologist. Exam includes routine lab work, sexually transmitted disease screening, Pap smear and mammogram (age 35 or older). PROVIDER SERVICES AT AMERIGROUP WEB SITE AND PROVIDER INQUIRY LINE AVA I LA B L E 2 4 / 7 / 36 5 Amerigroup now provides an online resource designed to significantly reduce the time your office spends on eligibility verification, claims status and precertification/notification. Visit our web site at health education materials, outreach and more to providers Monday through Friday from 8:00 a.m. to 6:00 p.m. Eastern Time. HEALTH SERVICES Amerigroup New Jersey, Inc. CARE MANAGEMENT SERVICES AT Amerigroup offers care management services to members who are likely to have extensive health care needs. The care manager works with you to develop individualized care plans. This includes identifying community resources, providing health education, monitoring compliance, assisting with transportation, etc TELEPHONE: For those times when you can t access the Internet, you can receive claims, eligibility and precertification/notification over the telephone anytime by calling Simply say your national provider identifier when prompted by the recorded voice. It s easy! The recording guides you through a menu of options, allowing you to select the information or materials you need. CALL DISEASE MANAGEMENT CENTRALIZED CARE UNIT (DMCCU) SERVICES AT AND ASK TO SPEAK TO A CARE MANAGER Information in this document effective April 1, 2010 LIVE WELL VIVA BIEN CLAIMS SERVICES NOTIFICATION PRECERTIFICATION/NOTIFICATION ONLINE AT BY PHONE AT OR FAX TO Members may call our 24-hour Nurse HelpLine for nursing advice 7 days a week, 365 days a year. When a member accesses this service, a report will be faxed to your office within 24 hours of receipt of the call. Amerigroup requires all submitters of institutional claims to use the UB-04 form. The same submission requirement applies to professional claims; the CMS-1500 (08-05) form approved by the National Uniform Claim Committee must be used. If a claim is received on a form other than the UB-04 or the CMS-1500 (08-05), the claim will be returned to the submitter for reprocessing. PROVIDER SERVICES WELL-WOMAN EXAM 24/7 NURSE HELPLINE AT The prospective process whereby licensed clinical associates apply designated criteria sets against the intensity of services to be rendered and a member s severity of illness, medical history and previous treatment to determine the medical necessity and appropriateness of a given coverage request. Prospective means the coverage request occurred prior to the service being provided. Telephonic, facsimile or electronic communication received from a provider informing Amerigroup of the intent to render covered medical services to a member. There is no review against medical necessity criteria; however, we do verify member eligibility and provider status (network and non-network). Notification should be provided prior to rendering services as referenced in the QRC. For services that are emergent or urgent, notification should be given within 24 hours or the next business day. NJPEC See the Oral Maxillofacial and Diagnostic Testing sections of this QRC. NJ FamilyCare D: No coverage for TMJ treatment, including Amerigroup offers DMCCU services to members with the following medical conditions: asthma, bipolar disorder, CAD, CHF, COPD, diabetes, HIV/AIDS, obesity, major depressive disorder and schizophrenia. DMCCU services include educational information like local community support agencies and events in the health plan s service area To provide faster and more accurate claims adjudication, Amerigroup offers electronic claims submission through electronic data interchange. Amerigroup accepts claims electronically through three clearinghouses: Availity (formerly THIN), Emdeon (formerly WebMD) and Capario (formerly MedAvant). The clearinghouse payer numbers are as follows: for Availity, for Emdeon and for Capario. Timely filing is defined as taking place within 180 days of the last date of service for the course of treatment. PAPER CLAIMS We use Optical Character Recognition (OCR) technology as part of our claims processing. Timely filing is defined as taking place within 180 days of the last date of service for the course of treatment. In order to use OCR technology, your claims must be submitted on original claim forms (CMS-1500 or UB-04) with dropout red ink, printed or typed (not handwritten) in large, dark font. Mail paper claims to: New Jersey Claims Amerigroup Community Care P.O. Box Virginia Beach, VA Please note: the American Medical Association and CMS-approved modifiers must be used appropriately based on the type of service and procedure code. CLAIMS PAYMENT DISPUTES AND APPEALS Claims payment disputes must be received on or before 90 calendar days following receipt of the explanation of payment. The provider dispute and correspondence submission form located at should be completed and sent with supporting documentation to: Payment Dispute Unit Amerigroup Community Care P.O. Box Virginia Beach, VA MEDICAL APPEALS Medical appeals may be initiated by the member or the provider, with or without the member s written consent. Medical appeals must be submitted within 60 calendar days from receipt of adverse determination. Medical appeals may be submitted in writing to: Appeals Department Amerigroup Community Care 399 Thornall Street, Ninth Floor Edison, NJ A provider submitting on behalf of a member may provide a letter or complete a provider appeals form located at For Amerivantage /Notification Guidelines, see the New Jersey Medicare Advantage Benefits Guide at Go to Office Support and click on QRC. THANK YOU FOR PARTICIPATING IN OUR NETWORK! Have you seen our web site lately? Check it out at We re always making changes adding new content, improving functions and using our online tools can save you a lot of time and money!

2 AMERIGROUP NEW JERSEY, INC. PRECERTIFICATION/NOTIFICATION COVERAGE GUIDELINES Thank you for participating in the Amerigroup network! We appreciate the quality health care you offer our members. This Quick Reference Card (QRC) has been developed for your convenience as an easy-access resource for precertification/notification requirements and other important Amerigroup information. For additional information about benefits and services, see your provider manual. If you have questions about this document or have a recommendation to improve it, please call We are always interested in hearing from our network health care professionals and improving our service to you so you can focus on serving your patients. Amerigroup does not require referrals to participating specialists. Refer to Aetna CPPs for all testing procedures. VFC: All administration codes require appropriate serum codes. BEHAVIORAL HEALTH/SUBSTANCE ABUSE Behavioral/mental health services, substance abuse services (diagnosis, treatment and detoxification), and costs for methadone and its administration are managed by the state for non-division of Developmental Disabilities (DD) enrollees, including New Jersey FamilyCare enrollees. Amerigroup retains responsibility for covering services, excluding the cost of drugs, to Medicaid enrollees who are clients of the DD. FamilyCare D Excludes mental health visits in outpatient hospital settings. Inpatient hospital services for mental health, including psychiatric hospitals, limited to 35 days per year. There is no limit to the number of days for CHIP beneficiaries under 19 years of age, pursuant to the Mental Health Parity and Addition Act (MHPAEA) of Outpatient benefits for short-term, outpatient evaluative and crisis intervention or home health/mental health services are limited to 20 visits per year. There is no limit to the number of visits for CHIP beneficiaries under 19 years of age, pursuant to the MHPAEA of Inpatient and outpatient services for substance abuse are limited to detoxification. There is no service limit for CHIP beneficiaries under 19 years of age, pursuant to the MHPAEA of CARDIAC REHABILITATION Coverage is limited to members with a history of acute myocardial infarction within the preceding 12 months, and/or previous coronary surgery and/or stable angina pectoris. CHEMOTHERAPY Inpatient is required for coverage of inpatient chemotherapy services. Outpatient Procedure: No precertification for Oncology and Ancillary No precertification is required for coverage of chemotherapy procedures when performed in outpatient settings by a participating facility, provider office, outpatient hospital or ambulatory surgery center. For information on coverage of and precertification requirements for chemotherapy drugs, please see the Pharmacy section of this QRC. Medications: See Pharmacy Section of this QRC. CHIROPRACTIC SERVICES is required for coverage of services. Chiropractic services are limited to treatment by means of manual manipulation of the spine. NJ FamilyCare D: Services performed by a chiropractor are excluded. DENTAL SERVICES Members are required to visit their primary care dentist for dental services. For temporomandibular joint services, see the Plastic/Cosmetic/Reconstructive Surgery section of this QRC. Medicaid and NJ FamilyCare A, B and C: Dental services are covered. Services include preventive dental services (exams, cleaning, space maintenance, sealants and fluoride) every six months for members up to age 20 and once a year for members ages 21 and older. NJ FamilyCare D: Coverage of dental services is limited to children under the age of 19. Covered dental services for Plan D: children under the age of 19 are the same as Medicaid and New Jersey FamilyCare Plan A, B and C. Orthodontic services are to be provided only to children in cases where medical necessity can be proven, such as developmental and facial deformities causing functional difficulties in speech and mastication or trauma. Orthodontic treatment will refer to limited, interceptive and comprehensive orthodontic treatment, as well as all other ancillary orthodontic services considered only when medical criteria for exemption, as noted above, have been met. Continuity of care through case completion will apply as follows: When an orthodontic case is in progress or retention as of July 1, 2010 When an orthodontic case required pretreatment extractions that were provided prior to July 1, 2010 When a client with an orthodontic case in progress changes HMOs Orthodontic services will not be continued upon termination from a NJ FamilyCare/Medicaid program. Members may contact Healthplex at DERMATOLOGY SERVICES Network Providers require no precertification for Evaluation and Management (E&M), testing and most procedures. Services considered cosmetic in nature are not covered. See the Diagnostic Testing section of this QRC. Visit to view specific service codes for precertification/notification requirements. DIAGNOSTIC TESTING No precertification is required for routine diagnostic testing. is required for coverage of Magnetic Resonance Angiogram (MRA), Magnetic Resonance Imaging (MRI), Computerized Axial Tomography (CAT), Positron Emission Tomography (PET), nuclear cardiac scans and video electroencephalogram. Any other nuclear radiology procedure requires precertification. through National Imaging Associates, Inc. (NIA) is required for coverage of MRA, MRI, CAT, nuclear cardiac and PET scans. Contact NIA at NIA will locate an imaging facility from the Amerigroup network of radiology service providers. No precertification is required for tests performed in conjunction with a precertified or emergent inpatient stay. Outpatient radiology services excluded from the precertification requirement (which may be provided at a hospital without precertification) include: radiation oncology services, services provided in association with an emergency room visit, observation stays and services associated with and on the same day as a precertified outpatient surgery performed at a hospital. NJ FamilyCare D: There is no coverage for thermography and thermograms.

3 DIALYSIS No precertification is required for coverage of dialysis procedures performed at a participating provider. is required for medications related to dialysis treatment. DURABLE MEDICAL EQUIPMENT and Certificate of Medical Necessity No precertification is required for coverage of glucometers and nebulizers, dialysis and end-stage renal disease equipment, gradient pressure aids, infant photo/light therapy, sphygmomanometers, walkers and orthotics for arch support, heels, lifts, shoe inserts and wedges by network providers. All Durable Medical Equipment (DME) billed with an RR modifier (rental) requires precertification. is required for coverage of certain prosthetics, orthotics and DME. For code-specific precertification requirements for DME, prosthetics and orthotics ordered by a network provider or network facility, please refer to and click on the Lookup Tool. See the Medical Supplies section of this QRC for guidelines related to disposable medical supplies. may be requested by completing a Certificate of Medical Necessity (CMN) - available at - or by submitting a physician order and Amerigroup Referral and Authorization Request form. A properly completed and physician-signed CMN must accompany each claim for the following services: hospital beds, support surfaces, motorized wheelchairs, manual wheelchairs, continuous positive airway pressure devices, lymphedema pumps, osteogenesis stimulators, transcutaneous electrical nerve stimulator units, seat lift mechanism, power operated vehicle, external infusion pumps, parenteral nutrition devices, enteral nutrition devices and oxygen. Amerigroup and the provider must agree on Health Care Common Procedural Coding System (HCPCS) and/or other codes for billing covered services. All custom wheelchair precertifications require an Amerigroup medical director s review. NJ FamilyCare D: See provider manual for items covered. EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT VISIT Use Early and Periodic Screening, Diagnosis and Treatment (EPSDT) schedule and document visits/encounters on a Centers for Medicare and Medicaid Services (CMS) 1500 claim form to receive incentive payments. Copays do not apply to EPSDT services. NJ FamilyCare D members receive limited coverage for EPSDT services. EDUCATIONAL CONSULTATION No notification or precertification is required. There is no coverage for smoking cessation. EMERGENCY ROOM No notification is required for emergency care provided in the emergency room. If emergency care results in admission, notification to Amerigroup is required within 24 hours or the next business day. For observation precertification requirements, see the Observation section of this QRC. EAR, NOSE AND THROAT SERVICES (OTOLARYNGOLOGY) No precertification is required for E&M, testing and most procedures. is required for tonsillectomy and/or adenoidectomy for members age 12 and older, nasal/sinus surgery, and cochlear implant surgery and services. Visit to view specific service codes for precertification/notification requirements. FAMILY PLANNING/SEXUALLY TRANSMITTED DISEASE CARE Infertility treatment is not covered. Covered services include pelvic and breast exams, lab work, drugs, and biological devices and supplies related to family planning (e.g., intrauterine device). No coverage is available outside the participating network. No precertification or notification is required for coverage of primary sterilization procedures. Member must be age 21 or older. A sterilization consent form is required for claims submission of primary sterilization procedures. GASTROENTEROLOGY SERVICES No precertification is required for network provider E&M, testing and most procedures. is required for upper endoscopy, bariatric surgery, including insertion, removal and/or replacement of adjustable gastric restrictive devices and subcutaneous port components. Visit to view specific service codes for precertification/notification requirements. See the Diagnostic Testing section of this QRC. GYNECOLOGY No precertification is required for E&M, testing and procedures. HEARING AIDS is required for digital hearing aids. Medicaid and NJ FamilyCare A, B and C: is required for coverage. NJ FamilyCare D: Hearing aid and audiology services are covered for NJ FamilyCare D members age 15 and younger, but are limited to $1,000 per ear every 24 months. HEARING SCREENING No notification or precertification is required for coverage of diagnostic and screening tests, hearing aid evaluations or counseling. NJ FamilyCare D: Hearing aid and audiology services are covered for NJ FamilyCare D members age 15 and younger, but are limited to $1,000 per ear every 24 months. HOME HEALTH CARE Medicaid and NJ FamilyCare A, B and C: Covered services are limited to skilled nursing, home health aide and medical social services that require precertification for coverage. NJ FamilyCare D: Covered services are limited to a skilled-nursing homebound beneficiary who is supervised by a registered nurse and home health aide, when the purpose of treatment is skilled care and social services required for the treatment of the member s medical condition. NJ Aged, Blind and Disabled (ABD): Home Health Services are covered under New Jersey Medicaid fee-for-service. Private duty nursing is covered by the Plan for A, B, C and D members until the 21st birthday. HOSPICE CARE /Notification is required for coverage of inpatient hospice services. Notification is required for coverage of outpatient hospice services. HOSPITAL ADMISSION Elective admissions require precertification for coverage. Emergency admissions require notification within 24 hours or the next business day. For preadmission lab testing, see the provider referral directory for a complete listing of participating vendors. Same-day admission is required for surgery.

4 LABORATORY SERVICES (OUTPATIENT) All laboratory services furnished by non-network providers require precertification by Amerigroup, except for hospital laboratory services provided for an emergency medical condition. For offices with limited or no office laboratory facilities, lab tests may be referred to an Amerigroup lab vendor. See provider referral directory for a complete listing of participating lab vendors. Medicaid and NJ FamilyCare A, B, C and D: Laboratory services are covered, except for routine testing related to administration of Clozapine and the other psychotropic drugs listed in Article B for non-dd clients. Reference Labs include: AccuReferral Lab, Bio Reference Lab, LabCorp and Quest. MEDICAL SUPPLIES No precertification is required for coverage of disposable medical supplies. NJ FamilyCare D: No coverage for medical supplies, except diabetic supplies. Hearing aid supplies are covered for NJ FamilyCare D members age 15 and younger but are limited to $1,000 per ear every 24 months. NEUROLOGY No precertification is required for network provider for E&M and testing. is required for neurosurgery, spinal fusion and artificial intervertebral disc surgery. Visit to view specific service codes for precertification/notification requirements. OBSERVATION No precertification or notification is required for in-network observation. If observation results in admission, notification to Amerigroup is required within 24 hours or the next business day. OBSTETRICAL CARE No precertification is required for coverage of obstetrical services when performed by a participating provider. Notification to Amerigroup is required at the first prenatal visit. Notification is required for coverage of emergency and obstetric admissions within 24 hours or the next business day. See the Diagnostic Testing section of this QRC. Two ultrasounds for normal pregnancy diagnosis are covered. OPHTHALMOLOGY No precertification is required for E&M, testing and most procedures. See the Plastic/Cosmetic/Reconstructive Surgery section of this QRC. Visit to view specific service codes for precertification/notification requirements. ORAL MAXILLOFACIAL No precertification is required for coverage of E&M-level office visits. is required for coverage of all other services. See the Plastic/Cosmetic/Reconstructive Surgery section of this QRC. NJ FamilyCare D: There is no coverage for TMJ treatment, including OTOLARYNGOLOGY SERVICES See the Ear, Nose and Throat Services (Otolaryngology) section of this QRC. OUT-OF-AREA/OUT-OF-PLAN CARE is required except for the coverage of emergency care (including self-referral) and OB delivery. See related services for precertification. Emergency admission to an out-of-area/out-of-network facility requires notification within one business day. OUTPATIENT/AMBULATORY SURGERY is required based on the procedure performed. See the Lookup Tool at PAIN MANAGEMENT Non-E&M-level testing and procedures require precertification for coverage. PERINATOLOGY Notification See Diagnostic Testing and Laboratory Services. PHARMACY The Pharmacy benefit covers medically necessary prescription and Over-The-Counter (OTC) medications prescribed by a licensed provider. Exceptions and restrictions exist, as the benefit is provided under a closed formulary/preferred Drug List (PDL). Please refer to the PDL for the preferred products within therapeutic categories, as well as requirements around generics, prior authorization, step therapy, quantity edits and the prior authorization process. Most self-injectable medications, self-administered oral specialty medications and many office-administered specialty medications are available through Caremark Specialty Pharmacy and require Prior Authorization (PA). To initiate a PA request, please call Please call Caremark at to schedule delivery once you receive a PA approval notice. For a complete list of drugs available through Caremark Specialty, please visit the Pharmacy section of our web site. The following injectable drugs and their counterparts in the same therapeutic class are examples of medications that require precertification by Amerigroup when administered from a provider s supply: Synagis, Epogen, Procrit, Aranesp, Neupogen, Neulasta, Neumega, Leukine, IVIG, Enbrel, Remicade, Kineret, Humira, Amevive, Synvisc, Erbitux, Avastin, Rituxan, Camptosar, Eloxatin, Gemzar, Ixempra, Tasigna, Taxol, Taxotere and Growth Hormone, Xolair, Lupron, Zoladex, Botox, Cinryze, Mozobil, Nplate, Octreotide, Berinert, Hemophilia Factor Products. To determine if a specific medication requires precertification, please refer to our Lookup Tool found in the Provider section of our web site under quick tools. NJ ABD and other dual-eligible individuals: Pharmacy is covered under New Jersey Medicaid FFS. PHYSIATRY is required for coverage of all non-e&m services and procedures related to pain management. PHYSICAL MEDICINE AND REHABILITATION No precertification is required for coverage of E&M codes. All other services require precertification. Outpatient Physical Therapy (OPT), Occupational Therapy (OT) and Speech Therapy (ST) are covered by Medicaid FFS. PLASTIC/COSMETIC/RECONSTRUCTIVE SURGERY (INCLUDING ORAL MAXILLOFACIAL SERVICES) No precertification is required for coverage of E&M codes. All other services require precertification. Services considered cosmetic in nature are not covered. Services related to a previous cosmetic procedure are not covered. Reduction mammoplasty requires an Amerigroup medical director s review. No precertification is required for coverage of oral maxillofacial E&M services. is required for coverage of trauma to the teeth, and oral maxillofacial medical and surgical conditions including TMJ. Visit to view specific

5 PODIATRY The benefit excludes routine hygienic care of the feet in the absence of a pathological condition. No precertification is required for coverage of E&M testing and most procedures when provided by a participating podiatrist. Visit to look up specific RADIATION THERAPY No precertification is required for coverage of radiation therapy procedures when performed in the following outpatient settings by a participating facility or provider: office, outpatient hospital and ambulatory surgery center. is required for coverage of services rendered in an inpatient setting. RADIOLOGY See Diagnostic Testing. REHABILITATION THERAPY (OUTPATIENT: OCCUPATIONAL THERAPY, PHYSICAL THERAPY AND SPEECH THERAPY) Medicaid and NJ FamilyCare A: Outpatient therapy services are covered by New Jersey Medicaid FFS. NJ FamilyCare B and C: Outpatient therapy services are covered by New Jersey Medicaid FFS for 60 days of therapy per year. NJ FamilyCare D: Outpatient physical therapy, occupational therapy and speech therapy services for nonchronic conditions, acute illness and injuries are covered under New Jersey Medicaid FFS. SKILLED NURSING FACILITY Skilled-nursing care is limited to the first 30 days of admission to a nursing facility. Covered benefits are limited to rehabilitation services for NJ FamilyCare B, C and D enrollees. is required for coverage of all care and services provided in a skilled-nursing facility. SLEEP STUDY is required. STERILIZATION Sterilization is a covered benefit for members age 21 and older. No precertification or notification is required for sterilization procedures, including tubal ligation and vasectomy. The sterilization consent form is required for claims submission for primary sterilization procedures. Reversal of sterilization is not a covered benefit. Sterilization services from a nonparticipating provider are not covered. TERMINATION OF PREGNANCY Elective, induced abortion and related services are covered by the New Jersey Medicaid FFS program. For benefit questions, members may call the New Jersey Medicaid Hotline at For New Jersey Medicaid FFS claims information, providers should call UNISYS at TRANSPORTATION For all cities and counties, members are directed to the County Board of Social Services or Logisticare at NJ FamilyCare B, C and D members are ineligible for routine transportation generally. NJ FamilyCare D: Coverage is limited to ambulance services for medical emergencies only. Transportation related to emergency room visits does not require precertification. Medicaid and NJ FamilyCare A, B and C: Medically necessary transportation (ambulance, medical intensive care units and invalid coach) is covered for any managed care or nonmanaged care covered benefit. The contractor shall make lower mode transportation services available to any enrollee requesting transportation to a nonhospital service provider when the nonhospital service provider is located greater than 30 miles from the enrollee s residence and whenever the contractor does not have a network/alternative provider of medically necessary covered services closer to the enrollee s home. Medicaid and all NJ FamilyCare Members: Lower-mode transportation is available to any member requesting transportation to any provider for a medically necessary covered benefit if the location is greater than 30 miles from the member s residence when there is no closer network provider available. AMERIGROUP PROVIDER SERVICES automated member eligibility, health education materials, outreach and more to providers. Please note the following definitions: PRECERTIFICATION VISION CARE (MEDICAL) No precertification is required for testing and procedures. is required for repair of eyelid defects. Services considered cosmetic in nature are not covered. VISION CARE (ROUTINE) NJ FamilyCare A, B and C: Coverage is limited to one routine eye exam per year. Members may contact Block Vision at eyeglass lenses once every 12 months for members under age 19 and age 60 and older. eyeglass lenses once every 24 months for members age 19 through 59 as medically necessary. NJ FamilyCare D: Members are eligible for a new pair of eyeglass lenses every 24 months or as medically necessary. Coverage is provided for contact lenses once every 24 months for specific pathological conditions and vision correction that cannot be improved to at least 20/70 or better with regular lenses. Members not meeting the medical necessity benefit can opt for contact lenses as a value-added benefit. Amerigroup will reimburse the lesser of usual and customary charges or $100. Provider Quick Reference Card REVENUE CODES To the extent the following services are covered benefits, precertification or notification is required for all services billed with the following revenue codes: All inpatient and behavioral health accommodations 0023 Home health prospective payment system 0240 through 0249 All-inclusive ancillary psychiatric 0632 Pharmacy multiple source 3101 through 3109 Adult day care and foster care AMERIGROUP ELECTRONIC DATA INTERCHANGE AT For more precertification/notification requirements on Amerigroup services, visit us online and click on Lookup Tool. Results of telephone or faxed precertification/notification requests will be provided by phone or fax within two business days. Note: Behavioral health information may be faxed to AMERIGROUP WEB SITE AND PROVIDER INQUIRY LINE AVAILABLE 24 HOURS A DAY, 7 DAYS A WEEK Amerigroup now provides an online resource designed to significantly reduce the time your office spends on eligibility verification, claims status and precertification/notification. Visit us at For those times when you can t access the Internet, you may receive claims, eligibility and precertification/notification over the telephone by calling Simply say your national provider identifier when prompted by the recorded voice. It s easy! The recording guides you through a menu of options, allowing you to select the information or materials you need. Well-woman exams are covered once per calendar year when performed by a PCP or in-network gynecologist. Exam includes routine lab work, sexually transmitted disease screening, Pap smear and mammogram (age 35 or older). PROVIDER SERVICES AT AMERIGROUP WEB SITE AND PROVIDER INQUIRY LINE AVA I LA B L E 2 4 / 7 / 36 5 Amerigroup now provides an online resource designed to significantly reduce the time your office spends on eligibility verification, claims status and precertification/notification. Visit our web site at health education materials, outreach and more to providers Monday through Friday from 8:00 a.m. to 6:00 p.m. Eastern Time. HEALTH SERVICES Amerigroup New Jersey, Inc. CARE MANAGEMENT SERVICES AT Amerigroup offers care management services to members who are likely to have extensive health care needs. The care manager works with you to develop individualized care plans. This includes identifying community resources, providing health education, monitoring compliance, assisting with transportation, etc TELEPHONE: For those times when you can t access the Internet, you can receive claims, eligibility and precertification/notification over the telephone anytime by calling Simply say your national provider identifier when prompted by the recorded voice. It s easy! The recording guides you through a menu of options, allowing you to select the information or materials you need. CALL DISEASE MANAGEMENT CENTRALIZED CARE UNIT (DMCCU) SERVICES AT AND ASK TO SPEAK TO A CARE MANAGER Information in this document effective April 1, 2010 LIVE WELL VIVA BIEN CLAIMS SERVICES NOTIFICATION PRECERTIFICATION/NOTIFICATION ONLINE AT BY PHONE AT OR FAX TO Members may call our 24-hour Nurse HelpLine for nursing advice 7 days a week, 365 days a year. When a member accesses this service, a report will be faxed to your office within 24 hours of receipt of the call. Amerigroup requires all submitters of institutional claims to use the UB-04 form. The same submission requirement applies to professional claims; the CMS-1500 (08-05) form approved by the National Uniform Claim Committee must be used. If a claim is received on a form other than the UB-04 or the CMS-1500 (08-05), the claim will be returned to the submitter for reprocessing. PROVIDER SERVICES WELL-WOMAN EXAM 24/7 NURSE HELPLINE AT The prospective process whereby licensed clinical associates apply designated criteria sets against the intensity of services to be rendered and a member s severity of illness, medical history and previous treatment to determine the medical necessity and appropriateness of a given coverage request. Prospective means the coverage request occurred prior to the service being provided. Telephonic, facsimile or electronic communication received from a provider informing Amerigroup of the intent to render covered medical services to a member. There is no review against medical necessity criteria; however, we do verify member eligibility and provider status (network and non-network). Notification should be provided prior to rendering services as referenced in the QRC. For services that are emergent or urgent, notification should be given within 24 hours or the next business day. NJPEC See the Oral Maxillofacial and Diagnostic Testing sections of this QRC. NJ FamilyCare D: No coverage for TMJ treatment, including Amerigroup offers DMCCU services to members with the following medical conditions: asthma, bipolar disorder, CAD, CHF, COPD, diabetes, HIV/AIDS, obesity, major depressive disorder and schizophrenia. DMCCU services include educational information like local community support agencies and events in the health plan s service area To provide faster and more accurate claims adjudication, Amerigroup offers electronic claims submission through electronic data interchange. Amerigroup accepts claims electronically through three clearinghouses: Availity (formerly THIN), Emdeon (formerly WebMD) and Capario (formerly MedAvant). The clearinghouse payer numbers are as follows: for Availity, for Emdeon and for Capario. Timely filing is defined as taking place within 180 days of the last date of service for the course of treatment. PAPER CLAIMS We use Optical Character Recognition (OCR) technology as part of our claims processing. Timely filing is defined as taking place within 180 days of the last date of service for the course of treatment. In order to use OCR technology, your claims must be submitted on original claim forms (CMS-1500 or UB-04) with dropout red ink, printed or typed (not handwritten) in large, dark font. Mail paper claims to: New Jersey Claims Amerigroup Community Care P.O. Box Virginia Beach, VA Please note: the American Medical Association and CMS-approved modifiers must be used appropriately based on the type of service and procedure code. CLAIMS PAYMENT DISPUTES AND APPEALS Claims payment disputes must be received on or before 90 calendar days following receipt of the explanation of payment. The provider dispute and correspondence submission form located at should be completed and sent with supporting documentation to: Payment Dispute Unit Amerigroup Community Care P.O. Box Virginia Beach, VA MEDICAL APPEALS Medical appeals may be initiated by the member or the provider, with or without the member s written consent. Medical appeals must be submitted within 60 calendar days from receipt of adverse determination. Medical appeals may be submitted in writing to: Appeals Department Amerigroup Community Care 399 Thornall Street, Ninth Floor Edison, NJ A provider submitting on behalf of a member may provide a letter or complete a provider appeals form located at For Amerivantage /Notification Guidelines, see the New Jersey Medicare Advantage Benefits Guide at Go to Office Support and click on QRC. THANK YOU FOR PARTICIPATING IN OUR NETWORK! Have you seen our web site lately? Check it out at We re always making changes adding new content, improving functions and using our online tools can save you a lot of time and money!

6 PODIATRY The benefit excludes routine hygienic care of the feet in the absence of a pathological condition. No precertification is required for coverage of E&M testing and most procedures when provided by a participating podiatrist. Visit to look up specific RADIATION THERAPY No precertification is required for coverage of radiation therapy procedures when performed in the following outpatient settings by a participating facility or provider: office, outpatient hospital and ambulatory surgery center. is required for coverage of services rendered in an inpatient setting. RADIOLOGY See Diagnostic Testing. REHABILITATION THERAPY (OUTPATIENT: OCCUPATIONAL THERAPY, PHYSICAL THERAPY AND SPEECH THERAPY) Medicaid and NJ FamilyCare A: Outpatient therapy services are covered by New Jersey Medicaid FFS. NJ FamilyCare B and C: Outpatient therapy services are covered by New Jersey Medicaid FFS for 60 days of therapy per year. NJ FamilyCare D: Outpatient physical therapy, occupational therapy and speech therapy services for nonchronic conditions, acute illness and injuries are covered under New Jersey Medicaid FFS. SKILLED NURSING FACILITY Skilled-nursing care is limited to the first 30 days of admission to a nursing facility. Covered benefits are limited to rehabilitation services for NJ FamilyCare B, C and D enrollees. is required for coverage of all care and services provided in a skilled-nursing facility. SLEEP STUDY is required. STERILIZATION Sterilization is a covered benefit for members age 21 and older. No precertification or notification is required for sterilization procedures, including tubal ligation and vasectomy. The sterilization consent form is required for claims submission for primary sterilization procedures. Reversal of sterilization is not a covered benefit. Sterilization services from a nonparticipating provider are not covered. TERMINATION OF PREGNANCY Elective, induced abortion and related services are covered by the New Jersey Medicaid FFS program. For benefit questions, members may call the New Jersey Medicaid Hotline at For New Jersey Medicaid FFS claims information, providers should call UNISYS at TRANSPORTATION For all cities and counties, members are directed to the County Board of Social Services or Logisticare at NJ FamilyCare B, C and D members are ineligible for routine transportation generally. NJ FamilyCare D: Coverage is limited to ambulance services for medical emergencies only. Transportation related to emergency room visits does not require precertification. Medicaid and NJ FamilyCare A, B and C: Medically necessary transportation (ambulance, medical intensive care units and invalid coach) is covered for any managed care or nonmanaged care covered benefit. The contractor shall make lower mode transportation services available to any enrollee requesting transportation to a nonhospital service provider when the nonhospital service provider is located greater than 30 miles from the enrollee s residence and whenever the contractor does not have a network/alternative provider of medically necessary covered services closer to the enrollee s home. Medicaid and all NJ FamilyCare Members: Lower-mode transportation is available to any member requesting transportation to any provider for a medically necessary covered benefit if the location is greater than 30 miles from the member s residence when there is no closer network provider available. AMERIGROUP PROVIDER SERVICES automated member eligibility, health education materials, outreach and more to providers. Please note the following definitions: PRECERTIFICATION VISION CARE (MEDICAL) No precertification is required for testing and procedures. is required for repair of eyelid defects. Services considered cosmetic in nature are not covered. VISION CARE (ROUTINE) NJ FamilyCare A, B and C: Coverage is limited to one routine eye exam per year. Members may contact Block Vision at eyeglass lenses once every 12 months for members under age 19 and age 60 and older. eyeglass lenses once every 24 months for members age 19 through 59 as medically necessary. NJ FamilyCare D: Members are eligible for a new pair of eyeglass lenses every 24 months or as medically necessary. Coverage is provided for contact lenses once every 24 months for specific pathological conditions and vision correction that cannot be improved to at least 20/70 or better with regular lenses. Members not meeting the medical necessity benefit can opt for contact lenses as a value-added benefit. Amerigroup will reimburse the lesser of usual and customary charges or $100. Provider Quick Reference Card REVENUE CODES To the extent the following services are covered benefits, precertification or notification is required for all services billed with the following revenue codes: All inpatient and behavioral health accommodations 0023 Home health prospective payment system 0240 through 0249 All-inclusive ancillary psychiatric 0632 Pharmacy multiple source 3101 through 3109 Adult day care and foster care AMERIGROUP ELECTRONIC DATA INTERCHANGE AT For more precertification/notification requirements on Amerigroup services, visit us online and click on Lookup Tool. Results of telephone or faxed precertification/notification requests will be provided by phone or fax within two business days. Note: Behavioral health information may be faxed to AMERIGROUP WEB SITE AND PROVIDER INQUIRY LINE AVAILABLE 24 HOURS A DAY, 7 DAYS A WEEK Amerigroup now provides an online resource designed to significantly reduce the time your office spends on eligibility verification, claims status and precertification/notification. Visit us at For those times when you can t access the Internet, you may receive claims, eligibility and precertification/notification over the telephone by calling Simply say your national provider identifier when prompted by the recorded voice. It s easy! The recording guides you through a menu of options, allowing you to select the information or materials you need. Well-woman exams are covered once per calendar year when performed by a PCP or in-network gynecologist. Exam includes routine lab work, sexually transmitted disease screening, Pap smear and mammogram (age 35 or older). PROVIDER SERVICES AT AMERIGROUP WEB SITE AND PROVIDER INQUIRY LINE AVA I LA B L E 2 4 / 7 / 36 5 Amerigroup now provides an online resource designed to significantly reduce the time your office spends on eligibility verification, claims status and precertification/notification. Visit our web site at health education materials, outreach and more to providers Monday through Friday from 8:00 a.m. to 6:00 p.m. Eastern Time. HEALTH SERVICES Amerigroup New Jersey, Inc. CARE MANAGEMENT SERVICES AT Amerigroup offers care management services to members who are likely to have extensive health care needs. The care manager works with you to develop individualized care plans. This includes identifying community resources, providing health education, monitoring compliance, assisting with transportation, etc TELEPHONE: For those times when you can t access the Internet, you can receive claims, eligibility and precertification/notification over the telephone anytime by calling Simply say your national provider identifier when prompted by the recorded voice. It s easy! The recording guides you through a menu of options, allowing you to select the information or materials you need. CALL DISEASE MANAGEMENT CENTRALIZED CARE UNIT (DMCCU) SERVICES AT AND ASK TO SPEAK TO A CARE MANAGER Information in this document effective April 1, 2010 LIVE WELL VIVA BIEN CLAIMS SERVICES NOTIFICATION PRECERTIFICATION/NOTIFICATION ONLINE AT BY PHONE AT OR FAX TO Members may call our 24-hour Nurse HelpLine for nursing advice 7 days a week, 365 days a year. When a member accesses this service, a report will be faxed to your office within 24 hours of receipt of the call. Amerigroup requires all submitters of institutional claims to use the UB-04 form. The same submission requirement applies to professional claims; the CMS-1500 (08-05) form approved by the National Uniform Claim Committee must be used. If a claim is received on a form other than the UB-04 or the CMS-1500 (08-05), the claim will be returned to the submitter for reprocessing. PROVIDER SERVICES WELL-WOMAN EXAM 24/7 NURSE HELPLINE AT The prospective process whereby licensed clinical associates apply designated criteria sets against the intensity of services to be rendered and a member s severity of illness, medical history and previous treatment to determine the medical necessity and appropriateness of a given coverage request. Prospective means the coverage request occurred prior to the service being provided. Telephonic, facsimile or electronic communication received from a provider informing Amerigroup of the intent to render covered medical services to a member. There is no review against medical necessity criteria; however, we do verify member eligibility and provider status (network and non-network). Notification should be provided prior to rendering services as referenced in the QRC. For services that are emergent or urgent, notification should be given within 24 hours or the next business day. NJPEC See the Oral Maxillofacial and Diagnostic Testing sections of this QRC. NJ FamilyCare D: No coverage for TMJ treatment, including Amerigroup offers DMCCU services to members with the following medical conditions: asthma, bipolar disorder, CAD, CHF, COPD, diabetes, HIV/AIDS, obesity, major depressive disorder and schizophrenia. DMCCU services include educational information like local community support agencies and events in the health plan s service area To provide faster and more accurate claims adjudication, Amerigroup offers electronic claims submission through electronic data interchange. Amerigroup accepts claims electronically through three clearinghouses: Availity (formerly THIN), Emdeon (formerly WebMD) and Capario (formerly MedAvant). The clearinghouse payer numbers are as follows: for Availity, for Emdeon and for Capario. Timely filing is defined as taking place within 180 days of the last date of service for the course of treatment. PAPER CLAIMS We use Optical Character Recognition (OCR) technology as part of our claims processing. Timely filing is defined as taking place within 180 days of the last date of service for the course of treatment. In order to use OCR technology, your claims must be submitted on original claim forms (CMS-1500 or UB-04) with dropout red ink, printed or typed (not handwritten) in large, dark font. Mail paper claims to: New Jersey Claims Amerigroup Community Care P.O. Box Virginia Beach, VA Please note: the American Medical Association and CMS-approved modifiers must be used appropriately based on the type of service and procedure code. CLAIMS PAYMENT DISPUTES AND APPEALS Claims payment disputes must be received on or before 90 calendar days following receipt of the explanation of payment. The provider dispute and correspondence submission form located at should be completed and sent with supporting documentation to: Payment Dispute Unit Amerigroup Community Care P.O. Box Virginia Beach, VA MEDICAL APPEALS Medical appeals may be initiated by the member or the provider, with or without the member s written consent. Medical appeals must be submitted within 60 calendar days from receipt of adverse determination. Medical appeals may be submitted in writing to: Appeals Department Amerigroup Community Care 399 Thornall Street, Ninth Floor Edison, NJ A provider submitting on behalf of a member may provide a letter or complete a provider appeals form located at For Amerivantage /Notification Guidelines, see the New Jersey Medicare Advantage Benefits Guide at Go to Office Support and click on QRC. THANK YOU FOR PARTICIPATING IN OUR NETWORK! Have you seen our web site lately? Check it out at We re always making changes adding new content, improving functions and using our online tools can save you a lot of time and money!