Important information for physicians and other health care professionals and facilities serving AmeriChoice members Spring 2010 AmeriChoice Tennessee s Provider University AmeriChoice Tennessee s Provider University is your one-stop shop to access valuable information about AmeriChoice s products, programs, and services. You can enroll in both required and optional courses to learn about your participation with AmeriChoice. Click here to enter the Provider University to review course descriptions, dates and times, and to easily register online. We are currently offering AmeriChoice orientation courses, including Secure Plus Complete, as well as an AmeriChoiceOnline full functionality demonstration session. These sessions are provided via WebEx which allows you to attend training without even leaving your practice. Also, they are scheduled several months in advance to give you time to plan ahead. We are excited about this opportunity to provide you continuous education and training and hope you will take advantage of this opportunity to broaden your knowledge of AmeriChoice products and services. If you have any questions regarding this new offering or a specific training session, please e-mail AmeriChoice_TN_Outreach@uhc.com. Articles of Importance to Read: Page 1 AmeriChoice Tennessee s Provider University Page 2 Avenues for Claim Issue Resolution E-Alert Program FAST FACTS: TennCare Pharmacy Prescription Limit Override Process Page 4 Updated Fraud, Waste and Abuse Controls Page 5 AmeriChoice Medicare Special Needs Plan (SNP) Adds Transportation Benefit effective January 01, 2010 News You Can Use About the AmeriChoice Medicare Special Needs Plan (SNP) Page 6 National Healthy First Steps Program Page 8 Dual-Eligible Special Needs Plans Important Information for Providers
Avenues for Claim Issue Resolution Access the self service options available through AmeriChoiceOnline at www.americhoice.com. You may submit a Claim Review to request a review of a processed claim. Call Customer Service and speak to a Customer Care Professional at 1-800-690-1606. If the issue remains unresolved after using the above avenues, you may request an escalation by e-mailing UHC_TN_Outreach@uhc.com. You may fax requests to 1-888-808-4420 if e-mail is not available in your practice. Please note you must include the following information for escalation: Date and Call Center Representative name or Claim review response from web inquiry If additional documentation is needed for review, follow the Provider Dispute Process: Submit Provider Dispute request with appropriate documentation to: AmeriChoice P.O. Box 5220 Kingston, NY 12402-5220 E-Alert Program AmeriChoice invites you to enroll into this innovative program. This program has been developed to communicate via e-mail important information about how your practice works with us. This program will assist AmeriChoice in getting information to the appropriate person in your practice. If you are interested in participating in this program, please register by logging into AmeriChoiceOnline then select e-alert Registration/Update in the right hand pane. FAST FACTS: TennCare Pharmacy Prescription Limit Override Process Beginning February 1, 2007, an additional override process was implemented to allow a TennCare enrollee who is subjected to prescription limits to receive prescriptions over and above the monthly limit, i.e. more than 5 prescriptions or 2 brand names per month. Two mechanisms will be available to go beyond the 5 prescriptions/2 brand limit: 1. Auto-Exemption List (formerly known as the Short List ) in place today Medications on this list automatically do not count towards the prescription limit The complete list can be viewed at: https://tnm.providerportal.sxc.com/rxcl aim/tnm/autoexemptlist.pdf 2. Prescriber Attestation List (also known as Soft Limits ) Starting February 1, 2007 Patients may access drugs on this list if the prescriber goes through the attestation process described below. The complete list can be viewed at: https://tnm.providerportal.sxc.com/rxcl aim/tnm/attestationlist.pdf page 2 Provider Relations: 1-800-690-1606
How does the prescriber attestation process work? TennCare has already paid for 5 prescription or 2 brand name drugs that month. The prescriber determines that an additional prescription is needed to prevent serious health consequences, and the drug in question is not on the Auto-Exemption List (formerly known as the Short List ). The drug the prescriber wants TennCare to cover is on the Prescriber Attestation List. The prescriber must initiate a telephone call to TennCare s pharmacy benefit manager, SXC Health Solution Corp. at 1-866-434-5524. For Acute medications, in which no greater than one month supply is requested, the prescriber must attest that without access to the requested drug, the patient is at high risk for health consequences that will be serious enough to result in hospitalization, institutionalization, or death within the next 90 days. For a drug that will be needed for longer than a one month period, the prescriber must review the patient s full medication profile with a clinical pharmacist at SXC and subsequently attest that no viable option exists to substitute one of the drugs the patient receives under the prescription limit for the drug for which the special exemption is sought. An individualized attestation form will be faxed to the prescriber immediately following the telephone call for signature. The form will then need to be signed and FAXED back to the SXC pharmacy manager as soon as possible to the number provided on the form. Requests for which a signed attestation form is not received within 3 days will be closed and a new request will then need to be called in. The member is notified by the prescriber the override has been placed. The enrollee asks the pharmacy to process the claim and receives the prescription that helps avert and immediate threat of severe consequences. Key Points Prescription limit override requests will not be considered for medications outside of the classes on the Prescriber Attestation Drug List. All Preferred Drug List, step therapy, clinical criteria, and utilization edits/criteria will apply. The TennCare Pharmacy Benefit Manager is SXC A copy of the latest PDL is posted at: https://tnm.rxportal.sxc.com/rxclaim/tnm/p DLtable.htm SXC contact information: For Members with pharmacy questions: 888-816-1680 (TennCare staffed) For prescribers needing a prior auth: 866-434-5524 (SXC staffed) page 3 Provider Relations: 1-800-690-1606
Website for TennCare Pharmacy Prior auth forms: https://tnm.providerportal.sxc.com/rxclaim/t NM/PAs.htm Updated Fraud, Waste and Abuse Controls In October 2009, AmeriChoice notified the provider community of changes to the manner in which it would implement controls to detect and prevent fraud, waste and abuse with regard to the TennCare and Medicare programs utilizing a robust claims editing tool called the Ingenix Claims Editing System or ices. The ices edits will serve to improve the accuracy of claims payment, in accordance with the fraud, waste and abuse protocols required for both the TennCare and Medicare programs. These edits are drawn from a variety of sources, such as the National Correct Coding Initiative (NCCI) which was developed by CMS to control incorrect coding in government health programs; as well as coding conventions defined in the American Medical Association's CPT manual, national and local policies and edits, coding guidelines developed by national societies, and the analysis of standard medical and surgical practices. The ices edits are more robust than AmeriChoice's prior claims edits, which did not always identify certain coding errors. In an effort to increase transparency to all AmeriChoice by UnitedHealthcare providers, the plan has created a suite of documents, each of which focus on particular elements of billing (eg. Modifiers, Bundling, Bilateral Procedures, Supplies) or on specific services (Anesthesia, DME). AmeriChoice by UnitedHealthcare has these policies posted to the website available to you for all your resource needs. While some of these documents may reflect actual changes and enhancements to the required controls, many of these serve to more clearly articulate to the providers, how claims are currently being paid. Additional information about these controls that should be considered: Fraud, waste and abuse controls are different than medical policies. Fraud, waste and abuse controls reflect appropriate billing practices (correct coding initiatives), assess when multiple billed codes should in fact be paid as one service (bundling edits) or evaluate against appropriate values for the services rendered (maximum frequency per day for different services, age/gender, and bilateral/unilateral edits). Medical policies reflect some level of medical necessity and/or medical appropriateness. These policies are implemented either through back-end review of medical records or through prior authorization or other means. But these policies are based on clinical evidence and input from specialty societies. Claims or claim-lines can be denied, even if a service was approved by a priorauthorization. While the service may be approved, if the claim is not billed appropriately, the fraud waste and abuse controls will edit the claim per the applicable coding protocols. page 4 Provider Relations: 1-800-690-1606
You will find a list of the AmeriChoice Policies which detail the specific claims edit(s) on our website- go to www.americhoice.com > Physicians> Reimbursement Policies AmeriChoice Medicare Special Needs Plan (SNP) Adds Transportation Benefit effective January 01, 2010 Beginning January 1, 2010, there will be some changes to our plan. The AmeriChoice Secure Plus Complete plan has made additional enhancements to the 2010 benefits. The plan continues to cover services offered by Original Medicare but has added much more. New benefits include a Non-Emergency Medical Transportation (NEMT) benefit. The NEMT is a benefit of the AmeriChoice Secure Plus Complete plan and is designed to help members get to their routine medical visits, whether for medical or dental appointments, to a pharmacy to pick up medication or for ongoing care such as dialysis. * Trip Limits. There is a 24 trip limit (50 miles) that can be taken annually. However, a trip is considered one way, e.g., a round trip would be two trips. When a member of the AmeriChoice Secure Plus Complete plan member calls to schedule a ride, they will be speaking with a LogistiCare professional, the vendor used for the SNP transportation. Types of transportation supplied can be: Car, van, taxi Wheelchair, lift-equipped, vehicle If a member is experiencing a medical emergency, please call 911 immediately. Hours of Operation: Reservations need to be made Monday - Friday, from 8:00 a.m. to 5:00 p.m. (local time). When to Call: Please call at least 3 days in advance to make a reservation, but not more than 2 weeks before the scheduled appointment. To Make a Reservation: Call 1-866-277-8963 Transportation Help Line: Call 1-866-418-9809 Members should use this number to call if the transportation is late in arriving or to schedule a ride from a facility. Hearing Impaired Members: Call TTY 1-866-288-3133 News You Can Use About the AmeriChoice Medicare Special Needs Plan (SNP) AmeriChoice Secure Plus Complete is a Medicare Advantage organization with a Medicare contract authorized to offer health care benefits in the State of Tennessee. As of January 1, 2010, the SNP plan is offered statewide for eligible Medicare beneficiaries. page 5 Provider Relations: 1-800-690-1606
Members of the AmeriChoice Secure Plus Complete SNP plan receive all the benefits covered under the Original Medicare program and so much more. Our AmeriChoice Secure Plus Complete SNP members have: No Monthly Plan Premium in addition to their Medicare Part B premium. No Copays for doctor office visits, preventive services, podiatry services, inpatient hospital care, outpatient surgery or emergency care. Health Products Catalog up to $340 in benefit credits every year to order personal health care products from our catalog. Choose anything from aspirin to vitamins and blood pressure monitors. Transportation up to 24 one-way trips to plan-approved locations every year. Part D Prescription Drug Coverage mail order available, too. Preventive Dental Benefits no copay for one oral exams, one cleaning every six months and one annual x-ray. Enhanced Dental Benefits no copay for diagnostic exams, routine restorations, simple extractions and more. Vision Services no copay for one routine eye exam every year and one pair of eyeglasses or contacts every two years. ($150 limit for eyewear every two years). Hearing Services no copay for one routine hearing exam every year and one individual hearing aid every two years ($750 limit for hearing aids every two years). *This is a partial listing of covered benefits and services. Limits, restrictions and co-pays may apply. If you would like more information about the AmeriChoice Secure Plus Complete plan, please access the self service options available through AmeriChoiceOnline at www.americhoice.com or call Customer Service and speak to a Customer Care Professional at 1-800-690-1606. National Healthy First Steps Program AmeriChoice by UnitedHealthcare is pleased to announce the implementation of an enhanced national model of care for Maternal and Neonatal Intensive Care Unit (NICU) management. Healthy First Steps TM (HFS) is an AmeriChoice program that has proven its efficacy over the years. Now, by leveraging best practices across our organization, we expect to improve prenatal, postpartum and newborn care. Important: Many of you will realize no material changes to the HFS program, processes or technology. However, others will benefit from the availability of enhanced obstetrical care management services that include behavioral health and social work components. Please continue to submit OB referrals in the same manner currently in place for your state. The new referral number for OB referrals is included in this notice. The Healthy First Steps model of care encompasses two components: Maternal Care and NICU. HFS-Maternal Care Model The objective of the HFS-Maternal care model is to create a structure that consistently: page 6 Provider Relations: 1-800-690-1606
Increases early identification and enrollment of expectant mothers Assesses the risk level of each member and directs them to proper care Increases the member's understanding of pregnancy and newborn care Encourages pregnancy and lifestyle selfmanagement Encourages appropriate pregnancy, postpartum and infant provider visits Fosters a physician-member partnership for care in non-emergent settings HFS-NICU Model The HFS-NICU care model will bring forward: Telephonic and on-site case management of NICU babies Utilization management, including quality management and improvement activities such as participating in action planning or quality measurement activities Engagement of caregiver/family to promote empowerment and provide educational materials Facilitation of discharge planning needs by coordinating with the hospital and families Reduction of hospital workload by levering resource efficiencies (Nurses will seek to collaborate and support current staff) OptumHealth Neonatal Resource Services (NRS), a business unit within UnitedHealth Group, is now delivering our NICU onsite and telephonic case management services. OptumHealth NRS is an agent working on our behalf and performing the same service as AmeriChoice did previously. Our goal in this transition is to promote continuity of service and care, encourage family involvement, and assist with the neonate s successful transfer home by coordinating discharge planning needs. We expect this increased support to improve NICU member outcomes and to grow your satisfaction with us as your partner in delivering care to our NICU members. NRS will support your hospital s NICU staff and neonatologists in their role as clinical decision-makers and optimize family involvement in the baby s care. Access to Providers in Key Specialties Medical support for the Healthy First Steps Model will be provided by physicians who are Board Certified in Maternal and Neonatal Medicine. These physicians will be providing clinical supervision and education to our staff as well as conducting peer to peer discussions with providers. The HFS program will be responsible for ensuring that members receive the services and education they need at the right time, in the right place and according to specific member needs. We will continue to send you more detailed communications as the HFS National Model implementation occurs in your area. We look forward to the opportunity to partner with you in a continued effort to improve pregnancy and newborn outcomes. Please note these NEW Provider OB Referral Numbers Phone: 1-800-599-5985 Fax: 1-877-353-6913 page 7 Provider Relations: 1-800-690-1606
Dual-Eligible Special Needs Plans Important Information for Providers Under the Medicare Modernization Act of 2003 (MMA), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. Special needs plans (SNPs) were allowed to target enrollment to one or more types of special needs individuals identified by Congress as: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions. The SNP plans maintain and monitor a network of Participating Providers including physicians, hospitals, skilled nursing facilities, ancillary providers and other health care providers through which Members obtain covered services. Key points about coordination of care for SNP Members include: SNP Members are encouraged to choose a Primary Care Physician (PCP) to coordinate their care. The SNP works with contracted PCP s who manage the health care needs of members and arrange for medically necessary covered medical services, including prior authorizations as necessary. Providers may, at any time, advocate on behalf of the member without restriction in order to ensure the best care possible for the member. To ensure continuity of care, Members are encouraged to coordinate with their PCP before seeking care from a specialist, except in the case of specified services (such as women s routine preventive health services, routine dental, routine vision, and behavioral health). Contracted health care professionals are required to coordinate member care within the SNP provider network. If possible, all member referrals should be directed to the SNP contracted providers. Referrals outside of the network are permitted, but only with prior authorization from the SNP. Key points related to billing for services for SNP Members include: Full-benefit dual eligible members and Qualified Medicare Beneficiaries (QMBs) are not responsible for Medicare cost-sharing under Title XIX of the Social Security Act. You must not charge these dual eligible members for cost-share or balance bill them for any part of the unpaid charges. Rather, you may bill AmeriChoice/Unison and then submit the secondary claim to the member's Medicaid coverage provider. For these individuals, the payment from AmeriChoice as well as any payment received from the Medicaid coverage provider should be considered payment in full. For services that are reimbursed by both Medicare and Medicaid for dual-eligible members, such as physician s services for which Medicaid pays the Medicare copayment, you are required to do one of the following: page 8 Provider Relations: 1-800-690-1606
Accept both Medicare and Medicaid payment and do not bill patient more than any co-payment required by the state, or If only accepting Medicare, do not balancebill dual-eligible members for copayments paid by Medicaid To learn about the full range of benefits and services for which members are eligible, your responsibility for cost-sharing (if any), and your right to reimbursement by both programs please contact call center at 1-800-690-1606.The SNP works with contracted PCP s who manage the health care needs of members and arrange for medically necessary covered medical services, including prior authorizations as necessary. 8 Cadillac Dr., Ste. 100 Brentwood, TN 37027 www.americhoice.com Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the AmeriChoice network. M44276 3/10