Provider Education Packet

Transcription

1 Provider Education Packet Spring 2015

2 Dear Provider; AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast are proud to present our spring 2015 Provider Education Packet. This booklet contains a compilation of our most important provider communications issued to your office over the last couple of months. We will continue to issue our Provider Education Packets on a bi-annual basis, next edition due this fall. Issuing our communications in this manner ensures that your office has received them and offers you the opportunity to discuss them with your assigned Account Executive, should the need arise. Your AmeriHealth Caritas Pennsylvania and/or AmeriHealth Northeast Account Executive serve as a crucial link between the plan and your office and they are able to assist you with the policies, procedures and practices set forth by the plan. All of the communications contained in this booklet may be found on and reproduced from our websites and Providers (top menu) Provider Training and Education (left-hand side menu, under Resources). Thank you for your continued participation in our network and your commitment to our members. If you have any questions, please contact your provider account executive. Our mission We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. Our values Advocacy Care of the poor Compassion Competence Dignity Diversity Hospitality Stewardship March 2015

3 Effective 9/1/2014 Geographic overview Account Executive Territories Erie Crawford Warren McKean Potter Tioga Bradford Susquehanna Wayne Forest Wyoming Cameron Sullivan Venango Elk Lackawanna Lycoming Mercer Clinton Pike Clarion Luzerne Jefferson Columbia Monroe Lawrence Clearfield Montour Union Butler Centre Armstrong Snyder Northumberland Carbon Northampton Beaver Mifflin Schuylkill Indiana Lehigh Juniata Allegheny Cambria Blair Dauphin Perry Lebanon Berks Bucks Westmoreland Huntingdon Montgomery Washington Cumberland Bedford Lancaster Somerset Chester Fayette Fulton Franklin Greene Adams York Philadelphia Delaware Clapper, Aileen Drew, Dana Garnecki, Frank Malafi, Barbara Miller, Tammy Moss, Wendy Reed, Dawn Rivera, Jeanine Sheehan, Mike Stimmel, Benjamin Stroud, Meghan Swain, Carrie Sypniewski, Michelle Yochem, Kimberly

4 Spring 2015 Provider Education Packet Table of Contents (Communications dates ranging from September 2014-February 2015) 1. Prospective Payment Reductions for Multiple Radiology Procedures 2. Advair Removal for Formulary 3. Significant Changes to Synagis Prior Authorization Criteria 4. Enterovirus D68 Update 5. Blood Lead Level Screening Requirements 6. Updated Provider Reference Guides 7. Department of Human Services (DHS) and ACP/AHN policy on billing members for services or requiring cash payments 8. Payment of Increased Primary Care Rate Required by the Patient Protection and Affordable Care Act Ends December 31, AmeriHealth Product Listing 10. NDC Provider Reminder 11. Winter Connections Newsletter Announcement 12. DHS Provider Quick Tips: Incomplete Provider Enrollment Applications will be Returned Effective February 1, CDC Pertussis Letter 14. DHS Provider Quick Tips: Most Common Billing Errors for Drugs Covered Under the Medical Assistance (MA) Program (re-issue) 15. Preventing Avoidable Readmissions: Free On-Demand Recorded CME Webinar Series 16. Inpatient and Hospital Emergency Room Billing Reminder 17. Billing Reminder: EPSDT Services 18. Claims Paper New HIPAA Format 19. Fast Facts: PPID Extension 20. Place of Service Codes Communication 21. Updated List of Durable Medical Equipment Vendors 22. Sign up for AmeriHealth Caritas s e-lert and/or AmeriHealth Northeast s Network News provider notifications

5 Prospective Payment Reductions for Multiple Radiology Procedures Summary: Coming in the 4 th quarter of this year, AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast will apply new prospective edits to radiology claims based on the current CMS Multiple Procedure Reduction payment policy and criteria, as it applies to radiology procedures. See below for more information on the application of these edits. Under the new policy, prospective edits apply to claims containing procedure codes with the Multiple Procedure indicator 4 on the Medicare Physician Fee Schedule (e.g. MRI, MRA, CT, CTA and Ultrasounds). Reductions apply to claims containing multiple imaging services, from the same code family, when billed with the same date of service. Reduction on the professional component applies to services rendered by a single provider, under one NPI. The procedure with the highest relative value unit (RVU) price for the professional component is reimbursed at 100% and the professional component for all secondary procedures is reduced by 25%. The imaging procedure with the highest technical component is paid at 100% and technical components for additional, less technical services in the same code family are reduced by 50%. Frequently Asked Questions: Does the policy apply to multiple imaging services within the same code family when billed on separate claims and processed at different times? Yes, it applies to subsequent claims for imaging services when billed with the same date of service. How does the policy apply to services billed globally in the Outpatient Hospital setting? For these claims, the Technical Component modifier TC is added to the appropriate codes, if not already present, to facilitate processing. What if a Distinct Procedural Service modifier is present? Edits do not apply when a Distinct Procedural modifier is present. If you have additional questions about this communication, please contact Provider Services at (AmeriHealth Caritas Pennsylvania /AmeriHealth Northeast ) or your Provider Account Executive. September 9, 2014

6 URGENT Important Pharmacy Change effective October 1, 2014 Advair Removal from Formulary On August 5, 2014, you received a notification that all formulations of Advair would be removed from AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast s Formulary as of August 6, To provide a smooth transition, AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast allowed until October 1, 2014, to substitute one of the formulary alternatives for your AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast patients that are currently receiving Advair. To date, our records indicate that many patients still have not been transitioned to a formulary alternative. What you need to do: By October 1, 2014, prescribe one of the formulary alternatives below for your AmeriHealth Caritas Pennsylvania and/or AmeriHealth Northeast patients currently receiving Advair. -OR- Submit prior authorization documenting the medical necessity of continuing Advair for your patient If you would like to receive a list of AmeriHealth Caritas Pennsylvania and/or AmeriHealth Northeast members, who are still currently receiving Advair via or hard copy, please contact your Account Executive. Any patient new to Advair therapy will now require prior authorization. Available formulary alternatives include: Dulera (brand of mometasone and formoterol) Symbicort (brand of budesonide and formoterol) Asmanex Twisthaler QVAR Serevent Flovent What we are doing: We are actively working with members, providers and pharmacies to educate them regarding the change and the need to take action to ensure continued therapy. If you have any questions, please contact Pharmacy Services at for AmeriHealth Caritas Pennsylvania or for AmeriHealth Northeast.

7 Respiratory Syncytial Virus (RSV) Season is Approaching Significant Changes to Synagis Prior Authorization Criteria The American Academy of Pediatrics (AAP) revised its guidance for Synagis prophylaxis on July, 28, These guidelines contain significant changes to the number of patients that are recommended to receive Synagis prophylaxis. Accordingly, AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast s prior authorization criteria has been updated to reflect the guidance from the AAP. Effective immediately: Synagis prophylaxis is NOT recommended for otherwise healthy infants born at 29 weeks, 0 days gestation or after. For children less than 12 months of age with a confirmed diagnosis of chronic lung disease of prematurity (CLD), or bronchopulmonary dysplasia (BPD), the patient must have required 28 days of continuous oxygen after birth to be considered for prophylaxis therapy. Attending child care and/or living with siblings younger than 5 years old are no longer considered to be risk factors when considering prophylaxis therapy. If an infant or child who is receiving Synagis immunoprophylaxis experiences a breakthrough Respiratory Syncytial Virus (RSV) infection, monthly prophylaxis should be discontinued. Synagis prophylaxis IS recommended for children months of age if the child: a. Has a confirmed diagnosis of chronic lung disease of prematurity (CLD), or bronchopulmonary dysplasia (BPD). Additionally the child must also have required 28 days of continuous oxygen after birth, and continues to require medical intervention (supplemental oxygen, chronic corticosteroids, diuretic or bronchodilator therapy within 6 months of the start of RSV season (November 1st). b. Will be profoundly immunocompromised during the RSV season. c. Will be undergoing cardiac transplantation during the RSV season. September, 2014

8 To submit a prior authorization request for Synagis, please visit: > Pharmacy > Specialty/Injectable Request Forms > Synagis Request Form or > Pharmacy > Specialty/Injectable Request Forms > Synagis Request Form If you have any questions regarding this notification, please contact Pharmacy Services at (AmeriHealth Caritas Pennsylvania) or (AmeriHealth Northeast). September, 2014

9 To: From: Network Primary Care Providers Michael Baer, M.D., Network Medical Director Date: October 1, 2014 Subject: Enterovirus D68 Update Summary: Enterovirus D68 symptoms, treatment recommendation and prevention advice. Enterovirus D68 (EV-D68) is a relatively uncommon non-polio associated enterovirus that has been associated with periodic outbreaks since its initial identification in California in The majority of patients with this virus have more typical viral symptoms, such as fever, cough, congestion and myalgias. However, as the media has reported, there have been several children in the Midwest who have developed significant respiratory distress. The majority of these patients have asthma as an underlying condition. The virus has been reported from at least a dozen states. There are no vaccines available for this disease. The treatment is symptomatic with analgesics or antipyretics, as well as OTC meds. If significant distress is present, then treatment is supportive with oxygen, bronchodilators if wheezing is present, and IV hydration. So far, most of the patients have been infants, children and teens. This is a population without prior exposure. EV-D68 is transmitted through respiratory secretions, such as sputum, nasal discharge and saliva. Transmission occurs through contact with aerosolized droplets or from contact with contaminated surfaces. Diagnosis should be considered when there are clusters of children with severe respiratory illness. Ultimate diagnosis may be achieved through performance of confirmatory lab testing, such as virus identification in cell cultures or by polymerase chain reaction (PCR) assays. Specimens may be taken from stool, rectal swabs, or respiratory specimens. Prevention is the real key to containment. This can be achieved through frequent hand washing with soap and water for at least 20 seconds. Covering the nose and mouth is also most effective in to limiting the spread of this condition. Practicing these measures now will help later this winter with viral illnesses.

10 Additional Resources: The American Academy of Pediatrics has created a webpage for parents on enterovirus D68 with additional information and FAQs: issues/conditions/infections/pages/reports-of-a-severe-respiratory-illness-on-the- Rise.aspx. An MMWR, Severe Respiratory Illness Associated with Enterovirus D68 Missouri and Illinois, 2014, was published and is available online at Questions: If you have questions about this communication, please contact your Provider Account Executive or the Provider Services department at for AmeriHealth Caritas Pennsylvania or for AmeriHealth Northeast. 2

11 Blood Lead Level Screening Requirements The Centers for Medicare and Medicaid Services (CMS) and Pennsylvania Department of Welfare have stringent requirements for Lead Toxicity Screening for all Medicaid eligible children. ALL Medicaid eligible children are considered at risk for lead toxicity and MUST receive blood lead level screening tests for lead poisoning PCP s are REQUIRED (regardless of responses to the lead screening questions) to ensure that children receive a blood lead level screening test beginning at nine months and again before their second birthday Any child who has not been tested at nine months and again before their second birthday is required to be tested following the Pennsylvania EPSDT Periodicity Schedule Risk questions should be asked at every visit thereafter PCPs are reimbursed a $10.00 fee for these services Submit claims with the CPT Code for reimbursement Visit the Provider Center at or or call AmeriHealth Caritas Pennsylvania s Provider Services at or AmeriHealth Northeast s Provider Services at September 2014

12 Provider Reference Guide Your provider account executive: Phone number: Fax number: Provider Services Referrals hours a day, 7 days a week. Member Services hours a day, 7 days a week. NAVINET Provides access to member eligibility, claims status inquiry, referral submission and retrieval, Care Gap and Member Clinical Summary reports and electronic copies of remittance advices and panel rosters. Dental services Services requiring referrals: All specialist care office visits. Nondiagnostic treatment and procedures. Self-referral services include: Optometrists and opticians. Family planning. OB visits. GYN visits. Medicare-covered services for members with Medicare A/B. Chiropractic initial visits. Diagnostic tests and procedures. 1. Each referral is valid for 180 days starting from the issue date. 2. Each referral is valid for unlimited visits, unless otherwise specified. 3. Specialists should contact Provider Services to extend a referral past 180 days and for additional services. No call to the PCP is necessary. 4. Referrals to nonparticipating providers always require prior authorization. Vision services Administered by Davis Vision, Laboratory services Some members have been assigned to Quest Diagnostics. If no lab is designated on the member s ID card, any participating laboratory may be utilized. Family planning services Members self-refer for routine family planning services and may go to any physician or clinic. CONNECT Hotline For family inquiries on Pennsylvania s Early Intervention System. PA tobacco cessation information Medical Assistance Transportation Program (MATP) QUIT-NOW ( ) For Medical Assistance recipients transportation inquiries regarding arranging non-emergency transportation. ER policy Prior authorization is not required for emergency room visits. Participating providers are not required to obtain prior authorization for emergent short procedure unit (SPU) or emergent 23-hour observation stays. Pharmacy services (PerformRx) Prior authorization is required for all prescriptions on multi-source branded products, injectables and nonformulary medications. For pharmacy authorization...fax: Online: > Providers > Pharmacy Services > Prior Authorization Web Submission Prior authorization and claims questions Services requiring prior authorization include, but are not limited to, the list below. Elective hospital admissions. Elective or non-emergent air ambulance transportation. Elective transfers for outpatient services. Ambulance transportation to and from the prescribed pediatric extended care center (PPECC) medical day care. Transplant evaluations and procedures. Medically necessary termination of pregnancy. All durable medical equipment (DME), prosthetics and orthotics over $500 in billed charges. DME under $500 not on the ACPA Fee Schedule. Wheelchair purchases and accessories, regardless of cost. All diaper quantities in excess of 300 per month. Contact J&B Medical for authorization (by phone at or fax at ). Enteral formula: age 21 and older regardless of cost. Under age 21: authorization needed for costs > $500 per month or for codes B4150 B4156 > $200 per month. Physical, speech and occupational therapy exceeding 24 visits in a calendar year. Skilled nursing facility. Bariatric surgery. Inpatient hospice care. Home health services after six visits per modality performed per calendar year (services may not exceed 60 days). Gastroenterology services (codes 91110/91111). Chiropractic treatment following initial visit. Cosmetic procedures or procedures that can be deemed cosmetic are not covered by Medical Assistance, regardless of treatment setting. For example: blepharoplasty, reduction mammoplasty, rhinoplasty, gastroplasty, ligation and stripping of veins. Cardiac or pulmonary rehabilitation. Inpatient rehabilitation. Any services or products not listed or in exceeding limits on the Medical Assistance Fee Schedule. Any service performed by a nonparticipating provider. Emergent admissions require notification by fax or phone within 48 hours or the first business day after the day services were rendered. Outpatient radiology services requiring prior authorization by National Imaging Associates Inc. (NIA) at or : CT/CTA. MRI/MRA. Nuclear cardiology/mpi. PET scan. CCTA.

13 Contact Information All claims Please indicate Resubmitted or Corrected Claim on the claim form (if applicable). AmeriHealth Caritas Pennsylvania Claims Processing Department P.O. Box 7118 London, KY Provider disputes (informal) Dissatisfaction not concerning medical necessity: AmeriHealth Caritas Pennsylvania Informal Provider Disputes P.O. Box 7329 London, KY Provider appeals (formal) Written request for the reversal of a medical denial. * Please indicate Provider Appeals on the envelope. Inpatient appeals: AmeriHealth Caritas Pennsylvania Provider Appeals Department P.O. Box 7307 London, KY Outpatient appeals: AmeriHealth Caritas Pennsylvania Provider Appeals Department P.O. Box 7316 London, KY Timely filing limits When submitting an EOB with a claim, the dates and dollars must all match to avoid a rejection of the claim. Initial claims days Resubmissions and corrections days COB submissions after primary payment days Nurse Call Line A confidential line for members to ask health-related questions. 24 hours a day, 7 days a week, call Retrospective review All retrospective authorization requests should be faxed to or mailed to: 8040 Carlson Road, Suite 500, Harrisburg, PA No telephonic calls for retrospective review will be accepted. EDI payer ID #22248 Revised January ACPA Electronic billing questions: Drug, alcohol and mental health services: All counties use the same phone number to access these services. County Phone Adams Berks Crawford, Mercer and Venango Cameron, Clarion, Clearfield, Elk, Forest, Huntingdon, Jefferson, McKean, Potter and Warren Dauphin, Lancaster, Lebanon, Cumberland and Perry Erie Franklin and Fulton Lehigh Northampton York Websites and addresses PA Department of Human Services AmeriHealth Caritas Pennsylvania website For questions or suggestions, PA Enrollment Services: Peer-to-Peer Hotline: Department Phone number Fax number Admission notification Bright Start (maternity services) obstetrical needs assessment form (ONAF) Concurrent review units* (to include skilled nursing facilities and inpatient rehabilitation) Unit Unit Unit *To determine the assigned unit, call (concurrent review prompt). Contracting Credentialing , option 2 Credentialing Check , option 2 (to inquire on status of CRED or for missing paperwork) DME authorization EPSDT unit Integrated Care Management , option Missed shift care reports or shiftcar box@ amerihealthcaritas.com Pediatric shift care Prior authorization (to include home care) Provider Services Retention unit Special Needs/ Rapid Response Unit provider.communications@amerihealthcaritaspa.com All other correspondence 8040 Carlson Road, Suite 500, Harrisburg, PA or fax

14 Provider Reference Guide Your provider account executive: Phone number: Fax number: Provider Services hours a day, 7 days a week. Member Services hours a day, 7 days a week. NAVINET Provides access to member eligibility, claims status inquiry, referral submission and retrieval, Care Gap and Member Clinical Summary reports and electronic copies of remittance advices and panel rosters. Dental services Vision services Administered by Davis Vision, Laboratory services If no lab is designated on the member s ID card, any participating laboratory may be utilized. Family planning services Members self-refer for routine family planning services and may go to any physician or clinic. CONNECT Hotline For family inquiries on Pennsylvania s Early Intervention System. PA tobacco cessation information Medical Assistance Transportation Program (MATP) QUIT-NOW ( ) Pharmacy services (PerformRx) Prior authorization is required for all prescriptions on multi-source branded products, injectables and nonformulary medications. For pharmacy authorization...fax: Online: > Providers > Pharmacy > Online PA Request Form. Prior authorization and claims questions ER policy Prior authorization is not required for emergency room visits. Participating providers are not required to obtain prior authorization for emergent short procedure unit (SPU) or emergent 23-hour observation stays. Emergent admissions require notification by fax or phone within 48 hours or on the first business day after the day services were rendered. Referrals: Generate electronic referral through NaviNet or issue paper referral forms Services requiring referrals: All specialist care office visits. Nondiagnostic treatment and procedures. Self-referral services include: Optometrists and opticians. Family planning. OB visits. GYN visits. Medicare-covered services for members with Medicare A/B. Chiropractic initial visits. Diagnostic tests and procedures. 1. Each referral is valid for 180 days starting from the issue date. 2. Each referral is valid for unlimited visits, unless otherwise specified. 3. Specialists should contact Provider Services to extend a referral past 180 days and for additional services. No call to the PCP is necessary. 4. Referrals to nonparticipating providers always require prior authorization. Services requiring prior authorization include, but are not limited to, the list below. Elective hospital admissions. Elective or non-emergent air ambulance transportation. Elective transfers for outpatient services. Ambulance transportation to and from the prescribed pediatric extended care center (PPECC) medical day care. Transplant evaluations and procedures. Medically necessary termination of pregnancy. All durable medical equipment (DME), prosthetics and orthotics over $500 in billed charges. DME under $500 not on the ACPA Fee Schedule. Wheelchair purchases and accessories, regardless of cost. All diaper quantities in excess of 300 per month. Contact J&B Medical for authorization (by phone at or fax at ). Enteral formula: age 21 and older regardless of cost. Under age 21: authorization needed for costs > $500 per month or for codes B4150 B4156 > $200 per month. Physical, speech and occupational therapy exceeding 24 visits in a calendar year. Skilled nursing facility. Bariatric surgery. Inpatient hospice care. Home health services after six visits per modality performed per calendar year (services may not exceed 60 days). Gastroenterology services (codes 91110/91111). Chiropractic treatment following initial visit. Cosmetic procedures or procedures that can be deemed cosmetic are not covered by Medical Assistance, regardless of treatment setting. For example: blepharoplasty, reduction mammoplasty, rhinoplasty, gastroplasty, ligation and stripping of veins. Cardiac or pulmonary rehabilitation. Inpatient rehabilitation. Any services or products not listed or in exceeding limits on the Medical Assistance Fee Schedule. Any service performed by a nonparticipating provider. Emergent admissions require notification by fax or phone within 48 hours or the first business day after the day services were rendered. Outpatient radiology services requiring prior authorization by National Imaging Associates Inc. (NIA) at or : CT/CTA. MRI/MRA. Nuclear cardiology/mpi. PET scan. CCTA.

15 Contact Information All claims Please indicate Resubmitted or Corrected Claim on the claim form (if applicable). AmeriHealth Northeast Claims Processing Department P.O. Box 7118 London, KY Provider disputes (informal) Dissatisfaction not concerning medical necessity: AmeriHealth Northeast Informal Provider Disputes P.O. Box 7329 London, KY Provider appeals (formal) Written request for the reversal of a medical denial. * Please indicate Provider Appeals on the envelope. Inpatient appeals: AmeriHealth Northeast Provider Appeals Department P.O. Box 7307 London, KY Outpatient appeals: AmeriHealth Northeast Provider Appeals Department P.O. Box 7316 London, KY Timely filing limits When submitting an EOB with a claim, the dates and dollars must all match to avoid a rejection of the claim. Initial claims days Resubmissions and corrections days COB submissions after primary payment days Nurse Call Line A confidential line for members to ask health-related questions. 24 hours a day, 7 days a week, call Retrospective review All retrospective authorization requests should be faxed to or mailed to: 8040 Carlson Road, Suite 500, Harrisburg, PA No telephonic calls for retrospective review will be accepted. Electronic billing questions: Drug, alcohol and mental health services: All counties use the same phone number to access these services. County Bradford, Centre, Columbia, Juniata, Mifflin, Montour, Northumberland, Schuylkill, Snyder, Sullivan, Tioga, Union and Wayne Phone Carbon, Monroe and Pike Clinton and Lycoming Lackawanna, Luzerne, Susquehanna and Wyoming Websites and addresses PA Department of Human Services AmeriHealth Northeast website For questions or suggestions, PA Enrollment Services: Peer-to-Peer Hotline: Department Phone number Fax number Admission notification Bright Start (maternity services) obstetrical needs assessment form (ONAF) Concurrent review* (to include skilled nursing facility and inpatient rehabilitation) Contracting Credentialing Credentialing Check (to inquire on status of CRED or for missing paperwork) DME authorization Integrated Care Management Member outreach Missed shift care reports or shiftcar box@ amerihealthnortheast.com Pediatric shift care Prior authorization (to include home care) Provider Services Rapid Response and Outreach Special needs unit provider.communications@amerihealthnortheast.com All other correspondence 8040 Carlson Road, Suite 500, Harrisburg, PA or fax EDI payer ID #77001 Revised January ACPA

16 8040 Carlson Road, Suite 500 Harrisburg, PA Important Reminder DPW and AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast s policy on billing members for services or requiring cash payments. As outlined in the Pennsylvania Department of Public Welfare s Medical Assistance bulletin entitled Payment in Full, AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast strongly remind all providers of the following point from the bulletin: Providers requiring Medicaid recipients to make cash payment for Medicaid covered services or refusal to provide medically necessary services to a Medicaid recipient for lack of pre-payment for such services are illegal and contrary to the participation requirements of the Pennsylvania Medical Assistance program. Additionally the Pennsylvania Code, 55 Pa. Code (a) statement of policy regarding full reimbursement for covered services rendered specifically mandates that: All payments made to providers under the MA program plus any copayment required to be paid by a recipient shall constitute full reimbursement to the provider for covered services rendered. A provider who seeks or accepts supplementary payment of another kind from the Department, the recipient or another person for a compensable service or item is required to return the supplementary payment. To review the complete MA Bulletin , Payment in Full, visit the Provider Center at OR ww.amerihealthnortheast.comproviderscommunicationsma Bulletins and RA Alerts. September 2014

17 8040 Carlson Road, Suite 500 Harrisburg, PA Payment of Increased Primary Care Rate Required by the Patient Protection and Affordable Care Act ends December 31, 2014 November 7, 2014 Dear AmeriHealth Caritas Pennsylvania and/or AmeriHealth Northeast Provider, In accordance with the methodology and/or guidelines established by the Pennsylvania Department of Human Services, pursuant to and in accordance with Section 1202 of the Pennsylvania Patient Protection and Affordable Care Act (ACA), AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast s increased primary care rates for certain primary care services ( ACA Enhanced Rates ) rendered by qualified physicians to eligible AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast members are scheduled to cease. These ACA Enhanced Rates were applicable to claims with dates of service beginning January 1, 2013 through December 31, Therefore, effective with dates of service beginning January 1, 2015, payment for claims submitted with codes for services that were previously eligible for the ACA Enhanced Rates will be reimbursed at the non-aca Enhanced Rates set forth in your current contract with AmeriHealth Caritas Pennsylvania/AmeriHealth Northeast. We appreciate your participation in our provider network and for your continued commitment to the care of our members. If you have questions, please contact your Provider Account Executive. Sincerely, Margaret Angello, RN, Executive Director AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast 11/ &

18 AmeriHealth Caritas Plans in Pennsylvania Pennsylvania Provider Services: Member Services: NORTHEAST Provider Services: Member Services: AmeriHealth Caritas Pennsylvania members are: Persons who are eligible to receive services under the HealthChoices program as determined by the Pennsylvania Department of Human Services. AmeriHealth Caritas Northeast members are: Persons who are eligible to receive services under the HealthChoices program as determined by the Pennsylvania Department of Human Services. Provider Services: Member Services: AmeriHealth Connect members are: years of age. Non-medically frail. Receiving an income up to 133 percent of the federal poverty level (FPL). Not eligible to participate in the Pennsylvania Department of Human Services Medical Assistance Program. Provider Services: Member Services: AmeriHealth VIP Care members are: Entitled to Medicare Part A and enrolled in Medicare Part B. Enrolled in the Pennsylvania Medical Assistance program. AHC

19 Coverage Areas for AmeriHealth Caritas Plans in Pennsylvania Montgomery HealthChoices New West HealthChoices New East Erie Susquehanna Warren McKean Tioga Bradford Potter Crawford Wayne Forest Wyoming Lackawanna Elk Cameron Sullivan Venango Lycoming Mercer Clinton Montour Luzerne Clarion Jefferson Columbia Monroe Lawrence Clearfield Union Centre Carbon Butler Northumberland Armstrong Snyder Mifflin Schuykill Beaver Lehigh Indiana Juniata Pike Northampton AmeriHealth Caritas Pennsylvania serves Medical Assistance recipients in 26 counties: Adams, Berks, Cameron, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Elk, Erie, Franklin, Forest, Fulton, Huntingdon, Jefferson, Lancaster, Lebanon, Lehigh, McKean, Mercer, Northampton, Perry, Potter, Venango, Warren and York. Allegheny Cambria Blair Perry Dauphin Berks Lebanon Huntington Westmoreland Cumberland Washington Lancaster Chester Somerset Bedford Fulton Franklin York Greene Fayette Adams HealthChoices Southwest HealthChoices Lehigh/Capital HealthChoices Zones Delaware Bucks Philadelphia HealthChoices Southeast AmeriHealth Northeast serves Medical Assistance recipients in 22 counties: Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming. Erie Crawford Warren McKean Potter Tioga Bradford Susquehanna Wayne AmeriHealth Connect Healthy PA Counties Zones 1, 2, 3, 5 and 6 Columbia Monroe Union Centre Carbon Northumberland Snyder Northampton Mifflin Schuykill Lehigh Juniata Perry Dauphin Berks Lebanon Bucks Huntington Montgomery Cumberland Lancaster Chester Philadelphia Fulton Franklin York Adams Delaware Jefferson Lawrence Clearfield Butler Armstrong Beaver Indiana Allegheny Cambria Blair Westmoreland Washington Somerset Bedford Greene Fayette Rating Area for QHP Forest Wyoming Lackawanna Elk Cameron Sullivan Venango Lycoming Pike Mercer Clinton Montour Luzerne Clarion HealthChoices Zones AmeriHealth Connect is a private coverage organization (PCO) in the Healthy Pennsylvania Program serving beneficiaries in 41 counties: Bedford, Blair, Bradford, Cambria, Cameron, Carbon, Centre, Clarion, Clearfield, Clinton, Columbia, Crawford, Elk, Erie, Forest, Huntingdon, Jefferson, Lackawanna, Lehigh, Luzerne, Lycoming, Mercer, Mifflin, McKean, Monroe, Montour, Northampton, Northumberland, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne and Wyoming. Erie Warren McKean Columbia Monroe Union Centre Carbon Northumberland Snyder Northampton Mifflin Schuykill Lehigh Juniata Perry Dauphin Berks Lebanon Bucks Huntington Montgomery Cumberland Lancaster Chester Philadelphia Fulton Franklin York Adams Crawford Forest Venango Elk Mercer Clarion Jefferson Lawrence Butler Armstrong Beaver Indiana Clearfield Allegheny Cambria Blair Westmoreland Washington Somerset Bedford Greene Fayette Susquehanna Tioga Bradford Potter Wayne Wyoming Lackawanna Cameron Sullivan Lycoming Pike Clinton Montour Luzerne AmeriHealth VIP Care Medicare Advantage Plan AmeriHealth VIP Care is a dual-eligible special needs (D-SNP) Medicare Advantage plan that serves Medicare and Medicaid eligible beneficiaries in Lancaster, Lehigh and Northampton counties. Delaware

20 November 24, 2014 Dear AmeriHealth Caritas Pennsylvania/AmeriHealth Northeast Provider: As previously communicated, all claims for outpatient medications must include the National Drug Code (NDC), NDC unit qualifier, and NDC units in addition to the HCPCS codes and HCPCS quantity. We are required to collect this information on all outpatient drug claims in order for the Department of Human Services (DHS), (formerly the Department of Public Welfare) to bill manufacturers for federal rebates as permitted by the Affordable Care Act. i-ii As a reminder, all claims for outpatient drugs will be validated for the presence of a(n): 1. Valid NDC 2. NDC that corresponds to the billed HCPCS 3. Accurate unit of measure for the NDC billed (F2, GR, ML, UN) 4. NDC quantity within appropriate FDA minimum and maximum levels If you have any questions regarding this requirement, please contact your Provider Account Executive. We thank you for your commitment to our members and for your continued participation in our network. Sincerely, Stephen Orndorff Director, AmeriHealth Caritas Pennsylvania/AmeriHealth Northeast i ii

21 Winter Connections Newsletter (November 2014), Issue 3 Availability AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast are pleased to announce the availability of the third and final edition of Connections, our provider newsletter, for 2014 on the provider center at or Connections is your link to AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast s important news, updates and provider resources. We hope your practice finds this edition informative and we welcome any comments or suggestions you may have at provider.communications@amerihealthcaritaspa.com or ProviderCommunications@amerihealthnortheast.com. Highlights of this edition are: Working together to prevent avoidable readmissions Update your Pennsylvania PROMISe Identification (PPID) with DPW now Free CME webinar series on preventing avoidable readmissions! NDC (National Drug Codes) reporting requirement AmeriHealth Caritas Pennsylvania welcomes dental providers Significant changes to Synagis prior authorization criteria AmeriHealth Caritas Pennsylvania s expanding diversity You can receive future editions of Connections and other important plan news and notification via our free service. Self-register on the provider center at Providers Services E-Lert Registration or Providers Services Network News.

22 PROVIDER QUICK TIPS Incomplete Provider Enrollment Applications Will Be Returned Effective February 1, 2015 Effective February 1, 2015, the Office of Medical Assistance Programs (OMAP), Bureau of Fee for Service Programs (BFFSP), Division of Provider Enrollment will return applications that are incomplete or do not have all of the required documents. Applications that are not complete or are missing required documents will be returned to the contact person listed on the application. The letter accompanying the returned application will identify the information that is missing from the application. The application, along with the missing information, will need to be resubmitted to the department. Applications and required documents can be submitted to the appropriate provider enrollment program office according to the instructions in the requirements document for your provider type. The most current version of the applications and information concerning required documents can be found on the department s provider enrollment website at the following link: If you have questions regarding the completion of an application or the required documentation, the appropriate toll-free numbers for your Provider Enrollment Program Office can be found at the following link:. ers/index.htm NOTE: Please do not send items requesting a return receipt of any kind to a PO Box address. Thank you for your service to our MA recipients. We value your participation. Check the department s website often at: BFFS 12/14 MA 548

23 DEPARTMENT OF HEALTH & HUMAN SERVICES October 9, 2014 Public Health Service Centers for Disease Control and Prevention (CDC) Atlanta GA Dear Colleague, Pregnant women and their babies are at increased risk for influenza-related complications, including premature labor and preterm birth. Additionally, pertussis outbreaks continue to occur in the United States with infants at highest risk of severe illness, including hospitalization and death. Influenza vaccination is recommended in any trimester for all women who are pregnant or who plan to become pregnant during the influenza season, and a pertussis vaccination (Tdap) is recommended between 27 and 36 weeks of each pregnancy.¹ Immunization rates for these vaccines are low, leaving many pregnant women and their infants unprotected against these serious vaccine-preventable diseases. We ask you to recommend the influenza vaccine to your pregnant patients throughout the current influenza season. We ask that you also recommend the Tdap vaccination to your pregnant patients as they enter their third trimester. Studies confirm that your recommendation and offer of vaccines are essential. One study showed that patients who were offered influenza vaccination during an office visit were 7 times more likely to be vaccinated for influenza than patients who reported their provider did not recommend or offer vaccination. Patients who received a recommendation alone were twice as likely to be vaccinated as those that received no recommendation.² We encourage you to adopt the National Adult Immunization Practice Standards to help ensure that your patients receive influenza and Tdap vaccinations as well as all other indicated vaccinations. We ask you to complete the following steps at each patient encounter: Assess the immunization status of each patient. Recommend the indicated vaccines to each patient Administer any necessary vaccines or, if you do not stock the vaccine, refer the patient to a provider or location that can vaccinate the patient. Document the vaccinations that your patient is given, ideally in your state or local immunization registry. Your pregnant patients might be concerned about receiving a vaccination while pregnant. Influenza and Tdap vaccines are safe and important for pregnant women and their infants. Infants in the first several months of life are at the greatest risk of severe illness from influenza and pertussis but are too young to be directly immunized, thus vaccination during pregnancy is critical. You play a crucial role in helping keep pregnant women and their newborns healthy. Assuring your patients are protected by recommended vaccines is key. For more information about the influenza vaccine, please visit: For more information about the Tdap vaccine and pregnancy, please visit: For information about all vaccines for pregnant women visit: We thank you for your dedication to ensure the health and safety of pregnant women and their infants. ¹ ²

24 DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention (CDC) Atlanta GA Reid B. Blackwelder, MD President American Academy of Family Physicians Vincenzo Berghella, MD President Society for Maternal-Fetal Medicine Gerald F. Joseph, Jr., MD, FACOG Vice President, Practice Activities American College of Obstetricians and Gynecologists Mitchel C. Rothholz, RPh, MBA Chief Strategy Officer American Pharmacists Association Edward R.B. McCabe, MD, PhD Senior Vice President & Chief Medical Officer March of Dimes Foundation James M. Perrin, MD, FAAP President American Academy of Pediatrics Marie-Michèle Léger, MPH, PA-C Director, Clinical Education American Academy of Physician Assistants Anne Schuchat, MD RADM, United States Public Health Service Assistant Surgeon General Director, National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention Lawrence L. Sanders, Jr, MD, MBA President National Medical Association Debbie Hatmaker, PhD, RN, FAAN Executive Director American Nurses Association Lynn Erdman, MN, RN, FAAN Chief Executive Officer Association of Women's Health, Obstetric and Neonatal Nurses Elena Rios, MD, MSPH President & CEO National Hispanic Medical Association Patrick Joseph, MD President National Foundation for Infectious Diseases Ginger Breedlove, CNM, PhD, APRN, FACNM President American College of Nurse-Midwives

25 PROVIDER QUICK TIPS Most Common Billing Errors for Drugs Covered Under the Medical Assistance (MA) Program The following guidelines are to be used for submission of pharmacy claims to the Pennsylvania MA program. The Affordable Care Act (ACA) includes language to extend the federal rebate to drugs covered by the Medicaid Managed Care Organizations (MCOs). The language requires the State to collect the NDC and NDC units for all outpatient drug claims, regardless if payment is made based on HCPCS code, in order to invoice the manufacturers for the Federal Rebates. For NCPDP claims, the drug form defines the correct unit of measure to be billed. NCPDP National Drug Code (NDC) units are in one of three categories: EACH (EA) is the correct billing unit for tablets, capsules, patches, non-filled syringes, international units, suppositories, etc. MILLILITER (ML) is the correct billing unit for liquids, suspensions, solutions, syrups, etc. GRAM (GM) is the correct billing unit for ointments, creams, balms, bulk powders, etc. Currently the PROMISe crosswalk for unit values for both Professional Drug (837P) and Institutional Outpatient Drug (837I) is: 837 unit GR - Gram crosswalks to NCPDP unit GM - Gram 837 unit ML - Milliliter crosswalks to NCPDP unit ML - Milliliter 837 unit UN - Unit crosswalks to NCPDP unit EA - Each 837 unit F2 - International Unit crosswalks to NCPDP unit EA - Each 837 unit ME - Milligram does not crosswalk to NCPDP unit. o Please convert the milligram to gram. For example, if the provider dispensed 100mg of an ointment, the provider should bill 0.1gm. When the actual number of units dispensed is a decimal quantity, the correct unit is a decimal, not a whole number. The Covered Drug Search displays the Drug Unit Description for any drug and/or NDC. It is located at the following link from the Department of Public Welfare s (the department s) website: BDCM 11/13 MA 548

26 PROVIDER QUICK TIPS The following are the correct units of measure for the drugs with the most common billing errors identified by the department. They are organized by Therapy Class/Drug Type. Check the department s website often at: Thank you for your service to our MA recipients. We value your participation. BDCM 11/13 MA 548

27 To: AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast Providers Date: January 21, 2015 Subject: Preventing Avoidable Readmissions: Free On-Demand Recorded CME Webinar Series Summary: This year AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast, in collaboration with the Pennsylvania Academy of Family Physicians (PAFP) Foundation, conducted a four-part live webinar series on preventing avoidable readmissions. This series offers practical advice on interventions you can use to help your patients avoid readmission to the hospital and improve health outcomes. AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast are pleased to make these on-demand, recorded versions available. Participation in the online webinar and completion of the post-session evaluation earns a.5 Free CME Category 1 credit per webinar. Webinar 1 recorded live October 7, 2014 Reducing Readmissions Using Interdisciplinary Teams Link to Webinar: Increase knowledge of the major themes in transitional care/er literature. Increase knowledge of transition-of-care tools (i.e., process inventory and hospital information tool). Increase use of strategies to reduce avoidable readmissions. Speaker: Lee Radosh, M.D., FAAFP, Director, Family Medicine Residency, Reading Hospital of Reading Health System Webinar 2 recorded live October 14, 2014 Medication Reconciliation Link to Webinar: Increase knowledge of gaps/inconsistencies in systems that impede medication reconciliation and resources that help. Increase knowledge of team-based framework in role-specific medication reconciliation delivery. Increase confidence to perform a complete and accurate medication history. Speaker: Linda Thomas-Hemak, M.D., President and CEO, Board Certified Internal Medicine/Pediatrics, Program Director, Internal Medicine, The Wright Center for Graduate Medical Education

28 Webinar 3 recorded live October 21, 2014 Action Plan to Prevent Readmissions Link to Webinar: Increase knowledge of the major themes in transitional care (building care compacts between hospitalists and PCPs). Increase knowledge of transition-of-care tools, (streamlining of data and enhancing communication between the staff). Increase use of strategies to reduce avoidable readmissions (building care management teams, transitions, navigator, community-wide care transitions network). Speaker: Jignesh Sheth, M,D., M.P.H., Vice President of Mission Accountability, The Wright Center for Graduate Medical Education Webinar 4 recorded live October 28, 2014 Self-Management Support Link to Webinar: Increase knowledge of the significant role of, and options for, patient self-management support, and obtainable goal-setting in achieving effective chronic disease management. Enhance understanding of role-specific, team-based engagement in patient self-management support efforts. Explore the enabling features of EMR meaningful use, and examples of available resources to promote effective patient self-management support. Speaker: Linda Thomas-Hemak, M.D., President and CEO, Board Certified Internal Medicine/Pediatrics, Program Director Internal Medicine, The Wright Center for Graduate Medical Education Follow these instructions to access the webinar recordings and to receive your CME credit: 1. Click on the links above or visit the plan website at or to access your webinar selection. 2. There will be step-by-step instructions to register, view the webinar and complete the post-session evaluation. 3. PAFP will issue your CME certificate. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME). The Pennsylvania Academy of Family Physicians is accredited by the ACCME to provide continuing medical education for physicians. The Pennsylvania Academy of Family Physicians designates each webinar listed for.5 AMA PRA Category 1 credit for each webinar attended. Physicians should only claim credit commensurate with the extent of their participation in these educational activities and should ensure that the licensing entity governing their particular license will consider these credits valid for applicable requirements.

29 Inpatient and Hospital Emergency Room Billing Reminder In an effort to obtain and manage data regarding the date and time of day AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast members access Hospital Inpatient and Emergency Room Services we are requiring that our participating facilities utilize the appropriate UB-04 claim form boxes to report admission date, hour, type and source of referral (fields 12-15) for these services. UB-04 Claim Form Field # Field Description Instructions and Comments 12 Admission Date The start date for this episode of care. For inpatient services, this is the date of admission. Right-justified 13 Admission Hour The code referring to the hour during which the patient was admitted for inpatient or outpatient care. Left-justified 14 Admission Type A code indicating the priority of the admission/visit. 15 Source of Referral for Admission or Visit A code indicating the source of the referral for this admission or visit. UB-04 Claim Form EDI Field # Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X- Required or Conditional* Required Required Required Required Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X- Required or Conditional Outpatient, Bill Types 13X, 23X, 33X, 83X- Required or Conditional* Required Required Required Required Outpatient, Bill Types 13X, 23X, 33X, 83X- Required or Conditional 12 Admission Date 2300/DTP Conditional Conditional 13 Admission Hour 2300/DTP Conditional Conditional 14 Admission Type 2300/CL1 Required Not Required 15 Source of Referral for Admission or Visit 2300/CL1 Required Not Required *Required fields must be completed on all claims. Conditional fields must be completed if the information applies to the situation or the service provided. Refer to the NUBC Reference Manual for additional information.

30 CODING CHART DATE/HOUR/TYPE/REFERRAL SOURCE Field Number Field Name Instructions 12 Admission Date Enter the start date of this episode of care. Use the MMDDCCYY format. 13 Admission Hour Enter the hour (using a two-digit code below) that the patient entered the facility. 1:00 a.m :00 a.m :00 a.m :00 a.m :00 a.m :00 a.m :00 a.m :00 a.m :00 a.m :00 a.m :00 a.m :00 noon :00 p.m :00 p.m :00 p.m :00 p.m :00 p.m :00 p.m :00 p.m :00 p.m :00 p.m :00 p.m :00 p.m :00 a.m Admission Type Enter one of the following primary reason for admission codes: 1 = Emergency 2 = Urgent 3 = Elective 4 = Newborn 5 = Trauma 9 = Information Not Available 15 Source of Referral for Admission or Visit All claims must be submitted within the required filing deadline of 180 days from the date of service. Enter one of the following source of admission codes: 1 = Physician Referral 2 = Clinic Referral 3 = HMO Referral 4 = Transfer from Hospital 5 = Transfer from SNF 6 = Transfer From Another Health Care Facility 7 = Emergency Room 8 = Court/Law Enforcement 9 = Information Not Available In the Case of Newborn 1 = Normal Delivery 2 = Premature Delivery 3 = Sick Baby 4 = Extramural Birth If you have any further questions regarding this communication, please refer to or Providers Billing Information (Under Billing heading) Claims Filing Instruction (pdf) or you may elect to contact your hospital account executive. January 26, 2015

31 BILLING REMINDER: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Providers choosing to bill for complete EPSDT screens, including immunizations, on the CMS 1500, UB-04 or the 837 electronic form must: Use V20.0, V20.1 or V20.2 as the primary diagnosis code Accurate payment of EPSDT claims will be determined solely by the presence of EPSDT modifiers to identify an EPSDT Claim. Failure to append EPSDT modifiers will cause claims to be processed as non-epsdt related encounters. Use one of the individual age-appropriate procedure codes outlined on the most current EPSDT Periodicity Schedule as well as any other EPSDT related service, e.g., immunizations, etc. Use EPSDT Modifiers as appropriate: EP - Complete Screen; 52 - Incomplete Screen; 90 - Outpatient Lab; U1 - Autism. Enter the applicable 2-character EPSDT Referral Code (in block 37 of the UB-04 or 10d of the CMS 1500) for referrals made or needed as a result of the screen: YO-other YV-Vision YH-Hearing YB-Behavioral YM-Medical YD-Dental (required for ages three and over) Of note: claims for EPSDT will process for payment regardless of any outstanding Coordination of Benefits (COB) information. It is not necessary to furnish COB information in order for EPSDT claims to adjudicate. Additional EPSDT Information For screening eligibility information and services required for a complete EPSDT screen, please consult the: EPSDT Program Periodicity Schedule and Coding Matrix Recommended Childhood Immunization Schedule Both schedules are available on either or Provider Resources EPSDT. You may direct EPSDT program specific questions to AmeriHealth Caritas PA's Provider Services Department at or AmeriHealth Northeast s Provider Services Department at January 27, 2015

32 February 17, 2015 To: AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast Participating Providers and Facilities Date: February 17, 2015 Subject: Effective April 1, 2015, Paper Claims that Do Not Meet New HIPAA 5010 X12 Format Requirements will be Rejected Summary: Beginning April 1, 2015, all electronic healthcare transactions must be transmitted in compliance with standards set forth by the Health Insurance Portability and Accountability Act (HIPAA) and the United States Department of Health and Human Services (HHS). This federal mandate requires health plans, clearinghouses and providers to use new standards when electronically submitting information. Thus, AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast must convert paper claims data into electronic claim information. Effective April 1, 2015, paper claims completed improperly will be rejected. AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast must adopt the required HIPAA 5010 X12 electronic claims submission format for both the CMS-1500 and UB-04 paper claim forms. In 2014 AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast began informing participating providers about the need for compliant paper claims to give providers time to adjust their billing systems to the new requirements. We are now implementing this billing requirement to align the conversion of paper claims to the mandated electronic formats. Action Required: Please refer to the attached grids for both the CMS-1500 and UB-04 required fields and billing guidelines for the mandated formats to ensure your claims are submitted correctly. Please note that effective April 1, 2015, these data elements for the 837 format will be required. Paper claims will be rejected if the required information is missing or inaccurate. If you have any questions, please contact your Provider Account Executive. You may also contact AmeriHealth Caritas Pennsylvania Provider Services at or AmeriHealth Northeast Provider Services at

33 February 17, 2015 CMS-1500 (02/12) AND UBO4 PAPER CLAIMS REJECT CRITERIA Field # CMS-1500 (02/12) Field/Data Element "Reject Statement" (Reject Criteria) Effective April 1, Patient s Name 3 Patient s Birth Date 3 Patient s Birth Sex 4 Insured s Name 5 Patient s Address( number, street, city, state, zip) phone 6 Patient Relationship to Insured 7 21 Insured's Address( number, street, city, state, zip) phone Information related to Diagnosis/Nature of Illness/Injury 24 Supplemental Information 24A 24B 24D Date of Service Place of Service Procedure, Services or Supplies "Member name is missing or illegible." (If first and/or last name are missing or illegible, the claim will be rejected.) "Member date of birth (DOB) is missing." (If missing month and/or day and/or year, the claim will be rejected.) "Member's sex is required." (If no box is checked, the claim will be rejected.) "Insured s name missing or illegible." (If first and/or last name is missing or illegible, the claim will be rejected.) "Patient address is missing." (If street number and/or street name and/or city and/or state and/or zip are missing, the claim will be rejected.) "Patient relationship to insured is required." (If none of the four boxes are selected, the claim will be rejected.) "Insured s address is missing." (If street number and/or street name and/or city and/or state and/or zip are missing, the claim will be rejected.) "Diagnosis code is missing or illegible." (The claim will be rejected.) "National Drug Code (NDC) data is missing/incomplete/invalid." (The claim will be rejected if NDC data is missing incomplete, or has an invalid unit/basis of measurement.) Date of service (DOS) is missing or illegible." (The claim will be rejected if both the From and To DOS are missing. If both From and To DOS are illegible, the claim will be rejected. If only the From or To DOS is billed, the other DOS will be populated with the DOS that is present.) "Place of service is missing or illegible." (Claim will be rejected.) "Procedure code is missing or illegible." (Claim will be rejected.) 24E 24F Diagnosis Pointer Line item charge amount "Diagnosis (DX) pointer is required on line [lines 1-6]. (For each service line with a From DOS, at least one diagnosis pointer is required. If the DX pointer is missing, the claim will be rejected.) "Line item charge amount is missing on line [lines 1-6]. (If a value greater than or equal to zero is not present on each valid service line, claim will be rejected.)

34 February 17, 2015 Field # 24G 24J Days/Units CMS-1500 (02/12) Field/Data Element Rendering Provider identification 26 Patient Account/Control Number 27 Assignment Number 28 Total Claim Charge Amount Signature of physician or supplier including degrees or credentials Billing Provider Information and Phone number Billing Provider Information and Phone number "Reject Statement" (Reject Criteria) Effective April 1, 2015 "Days/units are required on line [lines 1-6]. (For each line with a From DOS, days/units are required. If a numeric value is not present on each valid service line, claim will be rejected.) "National provider identifier (NPI) of the servicing/rendering provider is missing, or illegible." (If NPI is missing or illegible, claim will be rejected.) "Patient Account/Control number is missing or illegible" (If missing or illegible, claim will reject) "Assignment acceptance must be indicated on the claim." (If "Yes" or "No" is not checked, the claim will be rejected.) "Total charge amount is required." (If a value greater than or equal to zero is not present, the claim will be rejected.) "Provider name is missing or illegible." (If the provider name, including degrees or credentials, and date is missing or illegible, the claim will be rejected.) "Billing provider name and/or address is missing or incomplete." (If the name and/or street number and/or street name and/or city and/or state and/or zip are missing, the claim will be rejected.) "Field 33 of the CMS1500 claim form requires the provider s physical service address." (If a PO Box is present, the claim will be rejected.) Field # 1 1 3a 8b 9a-e UB-04 Field/Data Element Billing Provider Name, Address and Telephone Number Billing Provider Name, Address and Telephone Number Patient Account/ Control Number Patient Name Patient Address "Reject Statement" (Reject Criteria) Effective April 1, 2015 "Billing provider name and/or address missing or incomplete." (If the name and/or street number and/or street name and/or city and/or state and/or zip are missing, the claim will be rejected.) "Field 1 of the UB04 claim form requires the provider s physical service address." (If a PO Box is present, the claim will be rejected.) "Patient account/control number is missing or illegible." (If the number is missing or illegible, the claim will be rejected.) "Member name is missing or illegible." (If first and/or last name are missing or illegible, the claim will be rejected.) "Patient address is missing." (If street number and/or street name and/or city and/or state and/or zip are missing, the claim will be rejected.)

35 February 17, 2015 Field # UB-04 Field/Data Element "Reject Statement" (Reject Criteria) Effective April 1, Patient Birth Date "Member DOB is missing." (If missing month and/or day and/or year, the claim will be rejected.) 11 Patient Sex "Member's sex is required" (If missing, the claim will be rejected.) 12 Admission Date 12 Admission Date 13 Admission Hour 14 Admission Type 15 Source of Referral for Admission or Visit 16 Discharge Hour "Admission Date is missing or illegible." (Use the bill type table to identify if it is an inpatient (IP) or outpatient (OP) claim; If it is OP, do not reject claim. If it is IP and a valid date is not billed, the claim will be rejected.) "Based on the date the claim was received, the admission date is a future date." (Use bill type table to identify if it is an IP or an OP claim. If it is OP, do not reject claim. If it is IP and a future date is billed, reject the claim.) "Admission hour is required." (Use bill type table to identify if it is an IP or OP claim; If it is OP, do not reject the claim. If it is IP and bill type is anything except 21x and a numeric value is not billed on the claim, the claim will be rejected.) "Admission type is required." (If a numeric value is not present, claim will be rejected.) "Source of referral for admission or visit is missing." (If claim has any bill type except 14x and the field is blank, claim will be rejected.) "Discharge hour is required." (Use type if bill table to determine if it is an IP or OP bill type. If IP, the frequency code is either 1 or 4, and this field is blank, claim will be rejected.) 17 Patient Discharge Status "Patient discharge status is required." (If left blank, claim will be rejected.) 42 Revenue Code "Revenue code is missing or illegible." (If the revenue code is missing or illegible, the claim will be rejected.) 45 Service Date 45 Creation Date 46 Service Days/Units 47 Line Item Charges "DOS is missing or illegible." (Claim will be rejected if the field is blank on any service line and the claim is submitted with an OP bill type.) "Creation date is missing or illegible." (If the creation date is missing or illegible, the claim will be rejected.) "Days/units are required on line. [Lines 1-22]. (For each line with a From DOS, days/units are required. If a numeric value is not present on each valid service line, the claim will be rejected.) "Line item charge amount is missing on line. [Lines 1-22]. (If a value greater than or equal to zero is not present, the claim will be rejected.) 47 Total Charges "Total charge amount is missing." (If a value greater than or equal to zero is not present, the claim will be rejected.) 50 Payer "Payer name is required." (If left blank, the claim will be rejected.) 52 Release of Information "Release of information certification indicator is required." (If blank, the claim will be rejected.) 53 Assignment of Benefits "Assignment of benefits certification indicator is required." (If left blank, the claim will be rejected.)

36 February 17, 2015 Field # UB-04 Field/Data Element 58 Insured's Name 59 Patient s Relationship 67A- Q 69 Other Diagnosis Codes and Present on Admission Indicator Admitting Diagnosis Code 70 Patient s Reason for Visit 74 Other/Procedure Date 74 Other/Procedure Date Attending Provider Identifiers: Name and NPI Attending Provider Qualifier Attending Provider Other ID# "Reject Statement" (Reject Criteria) Effective April 1, 2015 "Member name is missing or illegible." (If first and/or last name are missing or illegible, the claim will be rejected.) "Patient's relationship to insured is required." (If blank, the claim will be rejected.) "Diagnosis codes are missing or illegible." (If diagnosis codes are missing or illegible, the claim will be rejected.) "Admitting diagnosis code is missing or illegible." (If it is an IP claim and field is blank or illegible, the claim will be rejected.) "Patient s reason for visit is missing." (If the claim is OP and field is blank, the claim will be rejected.) "Based on the date the claim was received, procedure date is a future date. (Use the bill type table to identify if it is an IP or an OP claim; If it is OP, do not reject the claim; If it is IP and a future date is billed, reject the claim.) "Procedure date is missing or illegible. (Use bill type table to identify if it is an IP or and OP claim. If OP, do not reject the claim. If IP and a valid date are not billed, reject the claim.) "Attending physician name and/or number is missing." (If attending physician name or NPI number is missing, the claim will be rejected.) "Attending provider qualifier is missing/ invalid." (The claim will be rejected if the Other provider ID is present and either: 1.) The 'Qualifier' box is blank or 2.) A qualifier other than 0B/1G/G2 is present. "Attending Provider NPI is missing."(the claim will be rejected if qualifier is present and NPI box is blank.)

37 Act quickly there is still time! The PPID and service location compliance date has been extended We have been notified by the Department of Human Services (DHS) that the compliance date to meet ACA and related Pennsylvania requirements has been extended. Therefore, all claims received by AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast after September 1, 2015, will no longer be reimbursed without an active PPID with unique service location extensions that match the addresses in our records. Claims from providers who are not enrolled in Medical Assistance or who have not accurately updated their enrollment information CANNOT be paid. Do not delay as DHS is experiencing extraordinary volume! Take advantage of this compliance extension and immediately: Review your practitioner records in the PROMISe system and update them as soon as possible by visiting: 1. or call (hours of operation: Monday Friday, 8 AM-4:30 PM) 2. If you feel your information registered with the state is correct, please review and correct your records with us to assure it matches. You can find a Provider Change form on our AmeriHealth Caritas Pennsylvania website at: And the AmeriHealth Northeast website at: Note: Providers are also required by the ACA to re-enroll in Medical Assistance every five years, which has a 2016 deadline. This requirement adds to the time these processes take, so again we encourage you take advantage of the extra time provided. If you have any questions, please contact your Provider Account Executive or AmeriHealth Caritas Pennsylvania Provider Services at or AmeriHealth Northeast Provider Services at February 20, 2015

38 Avoid claim denials by proper use of place of service code (POS) 21 According to CMS policy, the place of service (POS) code used should indicate the location in which a patient received a face-to-face service. In the case of an interpretation and report, the POS billed should indicate where the patient received the technical component of the service. However, when a patient is registered as a hospital inpatient (POS 21), CMS advises that providers acknowledge the patient s inpatient status by billing POS 21 regardless of where the service is actually rendered. For example, if a previously admitted patient is taken to the hospital outpatient department to receive a service, the service should be billed with POS 21, not POS 22 (outpatient hospital). Durable medical equipment (DME), including but not limited to: prosthetics, orthotics and enteral feeding supplies can be delivered to the patient or to his or her home prior to discharge, but vendors may not bill for these items prior to the day of discharge from the hospital. For DME, the POS billed should reflect where the item will be used, rather than POS 21. Beginning March 31, 2015, AmeriHealth Caritas Pennsylvania and AmeriHealth Northeast will expect providers to follow these billing guidelines. Services billed for patients who are registered inpatients will be denied if billed with a POS other than 21. DME, prosthetics, orthotics and supplies billed prior to the day of discharge will also be denied. If you have questions, please contact your Provider Account Executive or the AmeriHealth Caritas Pennsylvania Provider Services department at or the AmeriHealth Northeast Provider Services department at February 23, 2015

39 Durable Medical Equipment Providers All Durable Medical Equipment (DME) Company Counties served Items supplied 1st Choice Medical Columbia, Montour, Northumberland General DME ABC Home Medical Supply Chester General DME Abet All DME, wheelchairs, hospital beds Advanced Health Services Crawford, Erie, Mercer, Venango Allegheny O & P Armstrong, Blair, Cambria, Cameron, Centre, Clarion, Clearfield, Elk, Fulton, Huntingdon, Indiana, Jefferson, McKean, Mifflin, Potter, Somerset Prosthetics and orthotics, breast prosthesis Allied OP Monroe (and surrounding) Prosthetics and orthotics American Home Medical Lehigh American Home Patient All American Homecare Supply Carbon, Lackawanna, Luzerne, Monroe, Pike, Wayne, Wyoming General DME American Surgical Supply Inc Berks, Lebanon, Lehigh, Schuylkill General DME Durable Medical Equipment Providers 1

40 Durable Medical Equipment Providers All DME Company Counties served Items supplied Animas Diabetic Care All Diabetic supplies, pumps Apria Healthcare Bucks Vent bundle, baths, beds, nebulizers, sleep and sleep-related, oxygen, enterals with supplies Apria Healthcare Lehigh (and surrounding area) Vent bundle, baths, beds, nebulizers, sleep and sleeprelated, oxygen, enterals with supplies Apria Healthcare Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, Warren Assist HomeCare Carbon, Columbia, Montour, Northumberland, Schuylkill General DME, mobility supplies Baird Respiratory Therapy Lehigh, Montgomery (will ship anywhere) Bay City Orthocare Crawford, Erie, Mercer, Venango, prosthetics and orthotics Berks Medical Equipment Berks Boas Surgical Berks, Bucks, Carbon, Chester, Lancaster, Lehigh, Northampton, Schuylkill, Warren County, prosthetics and orthotics Brotherston Home Care Inc Adams, Berks, Bradford, Bucks, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, York Respiratory supplies, general DME, vent bundles Burmans Medical All Wound care, urologic, nebulizers, NPWT, diabetic monitors, specialty pharmaceuticals (injectable meds for HEP), breast pumps Durable Medical Equipment Providers 2

41 Durable Medical Equipment Providers All DME Company Counties served Items supplied Cambria Medical Supply Blair, Erie Care Plus Oxygen All Baths, beds, respiratory supplies, wheelchairs and seating, oxygen Caregivers America Medical Supply Carbon, Lackawanna, Luzerne, Monroe General DME CCS All Urologic, ostomy CCS All Diabetic, omnipod, ostomy Clear Care Corporation Clearfield, breast prosthesis and fitting Cocco Enterprises Philadelphia Prosthetics and orthotics Cole Care Cameron, McKean, Potter, Western Tioga Columbia Ancillary Services Clearfield, Columbia Cooney Medical Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming and wound vacs CPO2 Inc for nearest location Cumberland, Franklin, Lackawanna, Mercer, Schuylkill, Tioga, Union Respiratory supplies Dick's Home Care Blair, Clearfield, Cameron DuBois Medical Cameron, Clarion, Clearfield, Elk, Forest, Jefferson, McKean, Mercer, Potter, Venango, Warren Durable Medical Equipment Providers 3

42 Durable Medical Equipment Providers All DME Company Counties served Items supplied Dynavox All Speech-generating devices Electromed All CF vests EME Medical Equipment Lancaster Endless Mountains Brace and Mobility Bradford, Potter, Sullivan, Tioga, mobility products Espositos Shoes Lackawanna, Luzerne Diabetic/custom shoes Family Medical Supply York For Your Health Medical Carbon, Lackawanna, Luzerne, Monroe, Northampton, Schuylkill Good Samaritan Home Medical Care Lebanon Guthrie Med Supply Depot Bradford, Lycoming, Potter, Susquehanna, Sullivan, Tioga, Wyoming, breast prosthesis Hanger Orthotics and Prosthetics Adams, Berks, Carbon, Clarion, Cumberland, Dauphin, Forest, Franklin, Fulton, Huntingdon, Jefferson, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Mercer, Monroe, Northampton, Perry, Pike, Venango, York Prosthetics and orthotics Har-Kel Inc All Harry J Lawall & Son Inc Montgomery Prosthetics and orthotics Durable Medical Equipment Providers 4

43 Durable Medical Equipment Providers All DME Company Counties served Items supplied Health Care Solutions at Home/Lincare for nearest location Allegheny, Armstrong, Beaver, Bedford, Berk, Blair, Butler, Cambria, Centre, Chester, Clarion, Crawford, Dauphin, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Lancaster, Lawrence, Mercer, Somerset, Venango, Warren, Washington, Westmoreland Respiratory supplies Hill-Rom All Hospital beds Homestar Medical Montour, Northumberland, Snyder, Union Homestar Medical Equipment Bucks, Carbon, Lehigh, Monroe, Northampton Hospital Drive Care Bradford, Tioga General DME Hub's Home Oxygen Bradford, Centre, Clinton, Columbia, Lycoming, Mifflin, Montour, Northumberland, Snyder, Sullivan, Susquehanna, Tioga, Union, Wyoming, respiratory supplies In Home Oxygen Berks, Lancaster, Lebanon, Lehigh, Northampton, Schuylkill, York (will ship anywhere), no sleep apnea supplies J & B Medical Supply All Incontinence supplies J and J Medical Inc Berks Orthopedic products KCI USA Incorporated All Wound care supplies Keystone Hearing Institute Dauphin, York Hearing care Keystone Medical Equipment Carbon, Lehigh, Luzerne, Monroe, Northampton, Schuylkill, mobility products, mastectomy Durable Medical Equipment Providers 5

44 Durable Medical Equipment Providers All DME Company Counties served Items supplied King of Prussia Pharmacy Montgomery DME, scales, specialty liners Lanza Respiratory and Home Medical Equipment Fayette Respiratory supplies, DME Lincare Corporation All, respiratory supplies Loyalsock Mobility Services Clinton, Lycoming, Sullivan, Union Mobility products Luzerne Medical Lackawanna, Luzerne McKesson Patient Care Solutions All (will ship) DME, wound care supplies, ostomy supplies, urologic supplies, CPM, custom orthotics, off-the-shelf orthopedic braces McNelis Home Care Carbon, Lackawanna, Luzerne, Monroe, Pike, Wayne Medcare Equipment Company Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, Warren Medical Express Depot All Diabetic supplies, pumps MP Total Care All Wound care, urologic supplies, respiratory supplies, diabetic supplies NeighborCare at Home Berks, Union Northeast Med Equipment Pike, Wayne NuMotion All Wheelchairs Durable Medical Equipment Providers 6

45 Durable Medical Equipment Providers All DME Company Counties served Items supplied Orthofix All Bone stimulator Otto Bock All Prosthetics and orthotics PA Artificial Limb Erie Prosthetics and orthotics Performance Biomedical Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming (will ship across state) Personal Support Medical Suppliers Venango Respiratory supplies PM Medical Products Carbon, Lackawanna, Luzerne, Monroe, Pike, Wayne Lymphodema supplies, mobility products, pediatric nebulizers, wound care supplies, pain management supplies, some general DME Prentke Romich All Speech-generating devices Presque Isle Orthopedic Lab Erie Prosthetics and orthotics Pro All Baths, beds, respiratory supplies, wheelchairs and seating, oxygen ProCair Inc Bradford, Potter, Tioga REMWorks Sleep Store Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, Westmoreland CPap, BiPap, sleep apnea supplies Durable Medical Equipment Providers 7

46 Durable Medical Equipment Providers All DME Company Counties served Items supplied Respirtech All CF vests Rotech Berwick Columbia, Montour, Northumberland General DME Royal Homestar LLC Lehigh Urologic supplies, general DME Royal Medical Supply Lehigh, Montgomery General DME, vent bundles Sacred Heart Medical Equipment Services Lehigh Smith and Nephew All Bone stimulators Stawr Medical Carbon, Monroe, Pike, Schuylkill Superior Oxygen Berks, Lawrence, Lehigh, Northampton, Schuylkill, York (will ship) Susquehanna Valley Mobility Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming Mobility products Susquehanna Ventures Bradford, Clinton, Lycoming, Sullivan, Tioga, Union, Wyoming, enterals T and B Medical Centre, Clearfield, Clinton, Blair, Huntingdon, Juniata, Mifflin Union Orthotics and Prosthetics Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, Westmoreland Prosthetics and orthotics Durable Medical Equipment Providers 8

47 Durable Medical Equipment Providers All DME Company Counties served Items supplied Valley Prosthetics Berks, Carbon, Lancaster, Lehigh, Monroe, Northampton, Schuylkill Prosthetics and orthotics Vantage Home Medical Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, Warren Wayne Health Services Pike, Wayne Wellspan Medical Equipment/EME Medical Equipment and Home Care Supplies Berks, Lancaster, Lebanon General DME West Side Medical Carbon, Lackawanna, Luzerne, Monroe General DME Wheelchairs and More Erie Youngs Medical Supply Berks, Dauphin, Lancaster, Lehigh, Luzerne, Monroe, Montgomery, Northampton, York Durable Medical Equipment Providers 9 540ACN

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