hps://providers.amerigroup.com/�� Provider Newsletter December 2018 NJ-NL-0213-18 December 2018 Table of Contents End of year message Page 2 Medicaid: Praconers’ rights during credenaling process Page 3 Pharmacy management informaon Page 3 Quarterly pharmacy formulary change noce Page 3 Provider Incenve Program and Quality Bonus Program for maternity care Page 4 Medicaid Provider Fraud Training Page 4 Cultural competency in health care Page 5 How to pull a PCP member lisng Page 6 Working with Amerigroup Community Care to manage noncompliant members Page 7 Congesve heart failure in African Americans Page 8 PCPs should assist members to establish a dental home Page 9 Medical Policies and Clinical Ulizaon Management Guidelines updates Page 10 Prior authorizaon requirements Page 11 Medicare Advantage: New Medicare Advantage plans, service area expansions effecve January 1, 2019 Page 12 Prior authorizaon requirements Page 13 Reimbursement Policy: Claims Requiring Addional Documentaon Page 14
Transcript
https://providers.amerigroup.com/��
Provider Newsletter
December 2018NJ-NL-0213-18
December 2018
Table of ContentsEnd of year message Page 2
Medicaid:Practitioners’ rights during credentialing process Page 3
Pharmacy management information Page 3
Quarterly pharmacy formulary change notice Page 3
Provider Incentive Program and Quality Bonus Program for maternity care
Page 4
Medicaid Provider Fraud Training Page 4
Cultural competency in health care Page 5
How to pull a PCP member listing Page 6
Working with Amerigroup Community Care to manage noncompliant members
Page 7
Congestive heart failure in African Americans Page 8
PCPs should assist members to establish a dental home Page 9
Medical Policies and Clinical Utilization Management Guidelines updates
Page 10
Prior authorization requirements Page 11
Medicare Advantage:New Medicare Advantage plans, service area expansions effective January 1, 2019
The holiday season is a time for reflection. I want to take this opportunity to highlight the success of the past year and thank you for your continued partnership.
Amerigroup Community Care has achieved a Commendable recognition from the National Committee for Quality Assurance (NCQA) for the second consecutive year. We are the only Medicaid plan in New Jersey to maintain this status for the past two years. The NCQA evaluates a plan’s performance based on consumer satisfaction, prevention and treatment. Amerigroup also
achieved a Long-Term Services and Supports Distinction in 2018, an honor that recognizes organizations for coordinating long-term services and supports that deliver efficient, effective person-centered care. These honors are due to the hard work of our provider partners who deliver effective care. Thank you for helping us meet these important goals.
Quality is foundational to everything Amerigroup does, and we’re committed to building on our accomplishments to provide a better health care experience for our members. We strongly believe that our value-based payment programs make a difference as we have over 80,000 members in physician panels that participate. These programs provide additional revenue opportunities for providers and close gaps in members’ care. If you are not currently participating in one of these arrangements and want to, please contact your Network Management representative or call us at 1-800-454-3730.
End of year message
These honors are due to the hard work
of our provider partners who deliver effective care.
Thank you for helping us meet these
important goals.
“”
In partnership with the state of New Jersey, Amerigroup became responsible for additional behavioral health services for NJ FamilyCare, MLTSS and Fully Integrated Dual Eligible Special Needs Plan members on October 1st. This also includes services for certain populations, including developmentally disabled individuals and those who suffer from opioid use disorders. We are excited that this integration of physical and behavioral health will improve outcomes overall. If you have any questions about these changes, please contact us at 1-800-454-3730.
In closing, we value your partnership and the work you do to meet the health care needs of some of the least fortunate of our neighbors. On behalf of Amerigroup, we wish you, your staff and your families happy holidays and the very best for the coming year!
Warm regards,
John KoehnPresident Medicaid Health Plan — NJAmerigroup Community CareNJ-NL-0205-18
Page 3 of 14
Medicaid
Pharmacy management information
Need up-to-date pharmacy information?Log in to our provider website to access our Formulary, Prior Authorization forms, Preferred Drug List and process information.
Have questions about the Formulary or need a paper copy?Call our Provider Services department at 1-800-454-3730.
Our Member Services representatives serve as advocates for our members. To reach Member Services, please call 1-800-600-4411 (TTY).NJ-NL-0196-18
Practitioners’ rights during credentialing process
The credentialing process must be complete before a practitioner begins seeing members and enters into a contractual relationship with a health care insurer. As part of our credentialing process, practitioners have certain rights as briefly outlined below.
Practitioners can request to:� Review information submitted to support their
credentialing application.� Correct erroneous information regarding a
credentialing application.� Be notified of the status of credentialing or
recredentialing applications.
The Council for Affordable Quality Healthcare (CAQH®) universal credentialing process is used for individual providers who contract with Amerigroup Community Care. To apply for credentialing with Amerigroup, go to the CAQH website and select CAQH ProView™. There is no application fee.
We encourage practitioners to begin the credentialing process as soon as possible when new physicians join a practice. Doing so will help minimize any disruptions to the practice and members’ claims.NJ-NL-0196-18
Quarterly pharmacy formulary change notice
At our first quarter 2018 Pharmacy and Therapeutics Committee meeting, formulary changes were reviewed and approved. Effective August 1, 2018, these changes were applied to all Amerigroup Community Care members.
View the newly applied formulary changes in the full Provider Update.NJ-NL-0197-18
Provider Incentive Program and Quality Bonus Program for maternity care
Amerigroup Community Care pays incentives to providers and quality bonuses to federally qualified health centers for completing maternal care visits for NJ FamilyCare members.
The following maternal care visits are eligible for the Provider Incentive Program (PIP) and Quality Bonus Program (QBP):
� Initial prenatal care � Subsequent prenatal care � Postpartum care
For additional information regarding our PIP or QBP, contact your Network Management representative, Provider Services (1-800-454-3730) or Quality Management (1-877-453-4080, Option 1).NJ-NL-0204-18
Medicaid Provider Fraud Training
Date and time:Wednesday, December 12, 201810 a.m.-12:30 p.m.
Location:Forensic Science Technology Center Auditorium1200 Negron Drive, Hamilton, NJ 08691
Topics: � Structure of State Medicaid program efforts � Medicaid regulatory framework � Documentation requirements for providers � Third-party liability � FWA obligations � Noncompliance
Program overview: Several state agencies — the Medicaid Fraud Division (MFD) of the State Comptroller’s Office, the Division of Medical Assistance and Health Services (DMAHS) in the Department of Human Services, and the Medicaid Fraud Control Unit (MFCU) in the Attorney General’s Office — work together with New Jersey’s managed care organizations (MCOs) to identify and recover funds attributable to fraud, waste and abuse (FWA) in the Medicaid program. This session is designed to give stakeholders — specifically Medicaid providers — a better understanding of best practices to prevent, avoid and detect FWA in the Medicaid managed care program.
Register: https://bit.ly/2RSQKxX
Due to space restrictions, attendance is limited to 190.
If you have questions, please call Tracy Livingston at 609-789-5054 or email him at [email protected].
Sponsors reserve the right to cancel or modify sessions without notice.NJ-NL-0207-18
Amerigroup Community Care has adopted the 15 national standards for Culturally and Linguistically Appropriate Services (CLAS) in health care to ensure that all members receive equal, quality and effective treatment by respecting the whole individual and responding to each individual’s needs and preferences.
To learn more about these standards and to obtain no-cost continuing medical education credits, please visit https://www.thinkculturalhealth.hhs.gov/clas.
Amerigroup is part of a corporate multicultural health initiative to develop strategies that provide responsive services and reduce health care disparities related to race, ethnicity and language. Strategies include community mapping to identify health disparities at a geographic level.
Educational resources Amerigroup provides educational resources for providers as well as clinical and office staff (https://providers.amerigroup.com/NJ > Provider Resources & Documents > Training Programs):� Cultural Competency Toolkit
The Cultural Competency Toolkit is an informative booklet that provides guidance in caring for diverse populations such as tips for successful encounters with patients; tips for office staff to enhance communication, nonverbal communication and patient care; a mnemonic for developing personalized care plans; tips to identify and address health literacy issues, planning effective written patient communications, communicating across language barriers and working with interpreters; and an interview guide for hiring office and clinical staff with diversity awareness. Culturally relevant guidance about the use of alternative or herbal medications, pregnancy and breastfeeding, infant health, substance abuse, physical abuse, sexual health and gender roles, communicating with the elderly, and pain management is also provided.
� MyDiversePatients.com Trainings MyDiversePatients.com Trainings provide information about health care disparities as different groups of people can have health challenges that may be unique to them. Topics include building trust, medication adherence barriers, creating an LGBT-friendly practice, breast cancer screening for African American women, reducing health care stereotype threats and moving toward equity in asthma care.
Language assistance servicesAmerigroup makes the following no-cost language assistance services available for our members with limited-English proficiency or hearing, speech or visual impairments:
� Over-the-telephone interpreter services are available by contacting Provider Services at 1-800-454-3730.
� Members can request that an interpreter accompany them to a provider’s appointment, through their case manager.
� Interpretation is provided by professional oral interpretive services through phone language line or locally contracted interpreter service vendors.
� TTY for the hearing impaired is available.
� All written member materials are produced in English and Spanish and are translated into other languages as needed. Braille, large print, audio and accessible electronic formats are also available for members upon request.
You can access your panel listing by logging in to the Amerigroup Community Care provider self-service website. Member panel listings are updated daily to make the most current member information available for review and download.
Access through our provider website: Access through the Availity Portal: � Go to https://providers.amerigroup.com/NJ
and select Login. � Go to https://www.availity.com and select Login. � Select Payer Spaces, then Amerigroup in the toolbar. � Go to the Resources tab and select Provider Self
Service. � Next, select Members in the orange Tools menu on the right side of the page. � Select PCP Member Listing on the list that appears. � Select TIN. � Select Download Listing for Entire TIN or select a specific individual or group provider.
The report will display in .xls format for currently assigned (active) members as well as members who were assigned to that provider but have left the panel in the previous month (inactive members).
In accordance with Amerigroup access and availability standards, appointments for new members should be provided within the time frames below:
Initial pediatric care Within three months of enrollment
Baseline physicalsWithin 180 days of initial enrollment or in accordance with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines
Baseline physicals for Division of Development Disabilities clients
Within 90 days of initial enrollment or in accordance with EPSDT guidelines
We encourage providers to speak with their Network Management representative about how to utilize PCP Member Listings to provide timely and quality care to their patients — our members.NJ-NL-0202-18
Working with Amerigroup Community Care to manage noncompliant members
In some instances, you may need our help to manage members who are noncompliant with medical treatment; fail to make or appear for appointments; or exhibit inappropriate, disruptive or threatening behaviors. Behaviors like these may relate to the existence of a special need or situation such as a developmental or physical disability, a cognitive impairment, an organic or behavioral mental illness, a non-stable housing situation, a high-risk pregnancy, or a chronic medical condition.
If you have concerns about a member’s behavior or compliance with treatment or need to request member reassignment to another provider better suited to meet the member’s physical and behavioral health care needs, please contact Provider Services (1-800-454-3730) or your Network Management representative. The matter will be promptly referred to the Health Care Management (HCM) department who will reach out to the member within one business day of receipt of the referral.
Care management can help with the following for noncompliant members: � Evaluate for care management services or refer the matter to the member’s care manager. � Provide education and counseling necessary to address the situation. � Perform a comprehensive needs assessment. � Coordinate appropriate medical and behavioral treatment and support services. � Advise the referring staff member whether or not a care management case was opened or if the member
should be reassigned to a specific PCP. � Assist with continuity of care if it is determined that member should be reassigned to another provider.
To request member reassignment, you need to provide documentation indicating the reason for the request and have Amerigroup approve the request. PCP reassignment is not approvable due to the member’s medical condition or need for services. PCPs must continue to provide care until the effective date of reassignment to the new PCP.
For further information, refer to the Provider Manual (https://providers.amerigroup.com/NJ > Provider Resources & Documents > Manuals & QRCs > New Jersey Provider Manual).NJ-NL-0203-18
The prevalence of heart failure in the United States has increased over the last two decades, and researchers predict a further increase of 25 percent by 2030 (Sharma et al., 2014). Research indicates African Americans have higher rates and earlier onset of heart failure than Caucasian Americans. Rates of associated morbidity and death are also higher in the African American population.
Risk factors that can be but are often not addressed in African Americans account for a large part of this disparity. These factors include but are not limited to hypertension, diabetes and obesity. The identification of modifiable risk factors and the use of current clinical guidelines for treatment of heart failure (that include the use of neurohormonal modifying agents) yield better health outcomes and minimize disparity.
RecommendationsIt is imperative that providers identify and mitigate risk factors for heart failure early. The following are recommendations for providing quality care to African Americans and addressing disproportionate rates of chronic heart failure among African Americans:� Increase screening for hypertension and aggressively
manage hypertension. Management of hypertension should include education and discussion regarding barriers to treatment adherence.
� Reduce sodium intake in patients to 1,200 mg per day.� Encourage smoking cessation, healthy diet, physical
activity, reduction of alcohol consumption and avoidance of illicit drugs.
� Increase diabetes and dyslipidemia screenings.� Treat heart failure according to standard
evidence-based guidelines, including a combination of neurohormonal modifying agents such as ACE inhibitors and beta-blockers.
� Studies show that the use of neurohormonal modifying agents to treat heart failure in African Americans can reduce mortality rates.
� Identify socioeconomic and environmental factors that impede a patient’s ability to comply with treatment.
Amerigroup Community Care is available to support you and your NJ
FamilyCare patients. If you feel one of our members could benefit from having a care manager, please call 1-800-452-7101, ext. 106-134-2111 to refer them to Care Management. Please leave a
voicemail with the member’s name, ID number, date of birth and the referring provider information. You and/or the member will be contacted within one
business day.
View the entire Congestive heart failure in African Americans article on our website to read about predominant modifiable and socioeconomic risk factors.
Reference:Sharma, A., Colvin-Adams, M. & Yancy, C. W. (May 2014). Heart failure in African Americans: Disparities can be overcome. Cleveland Clinic Journal of Medicine, 81(5), 301-311. doi: 10.3949/ccjm.81a.13045NJ-NL-0200-18
To learn more about heart failure and health care disparities, please visit the Centers for Disease Control and Prevention website or the Department of Health Minority and Multicultural Health website.
PCPs should assist members to establish a dental home
Effective July 1, 2018, Liberty Dental Plan became the new dental vendor for Amerigroup Community Care. Search for primary care dentists at www.libertydentalplan.com/AmerigroupNJ or contact Liberty Dental Plan at 1-833-276-0848 (TTY 711), Monday-Friday, 8 a.m.-8 p.m. for assistance.
According to the American Academy of Pediatrics (AAP), dental caries — or tooth decay — is the most common chronic disease in children in the U.S. Dental caries are a silent disease that disproportionally affects poor, young and minority populations.
Although PCPs have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home.
Here’s what you can do:� Partner with a primary care dentist in the
Liberty Dental network for patient referrals.� Refer your child patients to be seen by a dentist
when the first tooth appears and no later than his/her first birthday.
� Complete the AAP Oral Health Risk Assessment Tool for children under age 6 or the ADA Caries Risk Assessment Form for ages 6 and up. Both forms are available online.
� Prescribe a fluoride supplement (drops, tablets or lozenges) to children whose water supply does not have enough fluoride.
� Fluoride varnish applications can be provided in the primary care setting by trained NJ Smiles providers every 3-6 months or up to four times a year, starting at tooth emergence through age 6. The PCP fluoride varnish application does not constitute a dental visit.
� Discuss risk factors for tooth decay and preventive measures to practice good oral hygiene, seek oral health care and to prevent transmission of caries-causing bacteria to infants and children.
� Educate family members to minimize exposure to natural or refined sugars in foods that can lead to dental caries and to establish lifelong nutritious eating patterns with infants and children.
� Check in with your patient at the next office visit to ensure that they are seeing a primary care dentist on a regular basis.
Dental services coverage:� Covered services are provided through Liberty
Dental Plan and include diagnostic and preventive services (e.g., exams, cleanings and space maintainers) and restorative services.
� Sealants and sealant repairs are covered for bicuspids and permanent molars once every three years for members under age 17 and are covered with prior authorization (PA) for members with special health care needs.
� PA is required for endodontic, periodontic, prosthodontic services, and oral maxillofacial medical and surgical conditions, including TMJ, and services for trauma of the teeth.
� Dental implants associated with retaining complete dentures are covered when medically necessary and with PA.
� Orthodontic services are covered when medically necessary through age 18 with PA. Medically necessary conditions include major functional problems such as facial trauma, developmental differences of facial bones and/or oral structures, and long-term physiological health needs.
Medical Policies and Clinical Utilization Management Guidelines updates
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Note: � Effective November 1, 2018, AIM Specialty Health® (AIM) Musculoskeletal Level of Care Guidelines,
Sleep Study Guidelines and Radiology Guidelines are now used for clinical reviews.� When requesting services for a patient (including medical procedures and medications), the Precertification
Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.
To search for specific policies or guidelines, visit https://medicalpolicies.amerigroup.com/search.
Medical PoliciesOn July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Amerigroup Community Care.
Clinical UM Guidelines On July 26, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Amerigroup. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.
View the list of newly approved Medical Policies and Clinical UM Guidelines in the July 2018 update.NJ-NL-0195-18
Effective February 1, 2019, PA requirements will change for the Subcutaneous Implantable Defibrillator system to be covered by Amerigroup Community Care.
PA requirements will be added to the following:� Subcutaneous Implantable Defibrillator system
— Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation (33270)
NJ-NL-0194-18
UPDATE: PA requirements for high-level, definitive drug testing delayed
In the last edition of the newsletter, Amerigroup Community Care communicated that the PA for high-level, definitive drug testing(s) was changing for NJ FamilyCare members.
There is a delay in implementing this change and a new effective date has yet to be determined.
If you have questions about this communication, please contact your Provider Relations representative.NJ-NL-0210-18
Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
To request PA, you may use one of the following methods: � Web: https://www.availity.com� Fax: 1-800-964-3627� Phone: 1-800-454-3730
Not all PA requirements are listed here. Detailed PA requirements are available to contracted and noncontracted providers on our provider website (https://providers.amerigroup.com/NJ > Provider Resources & Documents > Quick Tools > Precertification Lookup Tool). Providers may also call us at 1-800-454-3730 for PA requirements.
New Medicare Advantage plans, service area expansions effective January 1, 2019
We are pleased to announce the launch of our Amerivantage Classic HMO, beginning January 1, 2019, in the following counties: � Atlantic� Bergen� Burlington� Camden
� Cumberland� Essex� Gloucester� Hudson
� Mercer� Middlesex� Monmouth� Morris
� Ocean� Passaic� Somerset� Union
The HMO premium is $0 and offers generous medical and prescription benefits, including erectile drug coverage, additional supplemental benefits such as eyewear and allowance for over-the-counter health items available at Walmart and CVS.
Service area expansions of Amerivantage Balance HMO: The Amerivantage Balance HMO will expand into the following counties effective January 1, 2019: � Atlantic� Bergen� Burlington� Camden
� Cumberland� Essex� Gloucester� Hudson
� Mercer� Middlesex� Monmouth� Morris
� Ocean� Passaic� Somerset� Union
The Balance HMO premium offers generous medical and prescription benefits, including erectile drug coverage and additional supplemental benefits such as eyewear and allowance for over-the-counter health items available at Walmart and CVS.
Amerivantage End-Stage Renal Disease (ESRD) expands into Morris County: The Amerivantage ESRD HMO will expand into Morris County beginning January 1, 2019. The Amerivantage ESRD is a Medicare Advantage Chronic Care-Special Needs Plan (CSNP). It offers medical coverage (Medicare Parts A and B), prescription drug coverage (Part D) and an option to receive care from out-of-network providers (providers that do not have a contract with the plan directly for certain services). This plan was designed specifically for Medicare beneficiaries diagnosed with ESRD and offers care coordination managed by DaVita VillageHealth.74837MUPENMUB
Page 13 of 14
Prior authorization requirements
Nivestym (filgrastim-aafi)
Effective January 1, 2019, prior authorization (PA) requirements will change for Part B injectable/infusible drug Nivestym (filgrastim-aafi) to be covered by Amerigroup Community Care for D-SNP members.
PA requirements will be added to the following:� Nivestym (filgrastim-aafi) — for treatment of febrile neutropenia, hematopoietic syndrome of acute
radiation syndrome, mobilization of autologous peripheral blood progenitor cells (PBPCs) into the peripheral blood, and severe chronic neutropenia (J3590)
Please note, the drug noted above is currently billed under the not otherwise classified (NOC) HCPCS J-code J3590. Since this code includes all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS code.NJ-NL-0188-18
Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
To request PA, you may use one of the following methods: � Web: https://www.availity.com� Fax: 1-844-765-5160� Phone: 1-844-799-4129
Not all PA requirements are listed here. Detailed PA requirements are available to contracted and noncontracted providers on our provider website (https://providers.amerigroup.com/NJ > Provider Resources & Documents > Quick Tools > Precertification Lookup Tool). Providers may also call us at 1-844-799-4129 for PA requirements.
Professional providers and facilities are required to submit additional documentation for adjudication of applicable types of claims. If the required documentation is not submitted, the claim may be denied. Amerigroup Community Care may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations.
Effective March 1, 2019, if an itemized bill is requested and/or required, then it must include the appropriate revenue code for each individual charge.
For additional information, please review the Claims Requiring Additional Documentation reimbursement policy at https://providers.amerigroup.com/NJ > Quick Tools > Reimbursement Policies > Medicaid/Medicare.NJ-NL-0131-18
