October 2012www.amerihealth.com/providers

Articles designated with an orange arrow include notice of ►changes or clarifications to administrative policies and procedures.

Inside this edition ICD-10

ICD-10 Spotlight: Know the codes ► HHS announces new ICD-10 compliance date of ►October 1, 2014

ADMINISTRATIVE Medicare Part D prescriber prescription verification ►requests (NJ only)

PHARMACYImportant change for the coverage of Adderall XR ► ®

PRODUCTSIntroducing AmeriHealth 65 ► ® Preferred HMO

MEDICALPolicy notifications posted as of September 21, 2012 ► New prior authorization requirements for AmeriHealth ►65® NJ HMO and AmeriHealth 65® Preferred HMO members effective January 1, 2013

Annual Synagis ► ® (palivizumab) distribution program

Coverage change for Plan B One Step ► ® (Levonorgestrel, Next Choice®)

HEALTH AND WELLNESS Members encouraged to get whooping cough vaccine ●to combat rising rates

Seasonal flu vaccine recommendations ● Case management: Help for your patients when they ●need it

Introducing AmeriHealth 65® Preferred HMO page 6

For articles specific to your area of interest, look for the appropriate icon:

Professional

Facility

Ancillary

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2012 www.dreamstime.com. All rights reserved.

This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.

The third-party websites mentioned in this publication are maintained by organizations over which AmeriHealth exercises no control, and accordingly, AmeriHealth disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage.

NaviNet® is a registered trademark of NaviNet, Inc.

CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. The AMA assumes no liability for data contained or not contained herein.

Partners in Health UpdateSM is a publication of AmeriHealth HMO, Inc. and its affiliates (AmeriHealth) created to provide valuable information to the AmeriHealth participating provider community. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the covered services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with AmeriHealth. This publication is the primary method for communicating such general changes. Suggestions are welcome.

Contact Information:

Provider CommunicationsAmeriHealth1901 Market Street 29th FloorPhiladelphia, PA 19103

providercommunications@amerihealth.com

John Shermer Managing Editor

Charleen BaseliceProduction Coordinator

AmeriHealth 65® NJ HMO has an accreditation status of Excellent from NCQA.

AmeriHealth HMO, Inc. has an accreditation status of Commendable from the National Committee for Quality Assurance (NCQA).

Reminder...

To replenish office supplies such as provider manuals and directories and maternity questionnaires, please submit your request through our online order form at www.amerihealth.com/providersupplyline.

In order to properly fulfill your request, you will need to provide some basic office information, including your NPI, mailing address, and office phone number. Orders are usually shipped within 24 hours and should arrive to you within 3 – 5 business days.

While filling out your request, you also have the option to sign up to receive provider email notifications from AmeriHealth. These notifications provide you with the latest information, including when a new edition of Partners in Health Update is available, and news alerts.

For providers without Internet access, call 1-800-858-4728 to place your order. Note: Calls to the Provider Supply Line should be related to supply requests only. All other provider inquiries, such as member eligibility or claims status, should be directed to Customer Service at 1-800-275-2583.

Request your office supplies through the Provider Supply Line

October 2012 | Partners in Health UpdateSM 3 www.amerihealth.com/providers

ICD-10 Spotlight:Know the codes

Each month, AmeriHealth will feature an example of how ICD-9 codes will translate to ICD-10 codes. We will present coding examples from different specialties and popular disease categories to demonstrate the granularity that the new ICD-10 code set will provide.

CODING CONVENTION: ICD-10 CODING BuRNS AND CORROSIONS (continued from last month)This article will convey the coding conventions used in assigning the appropriate codes for burns and corrosions.

ICD-10 makes a distinction between burns and corrosions. In addition to the distinction, there are coding conventions that are essential in attaining the correct code assignment. These conventions include:

SequencingWhen more than one burn/corrosion is present, sequence the code that reflects the highest degree first. ● When the reason for the admission or encounter is for treatment of external burns/corrosions, sequence the code ●that reflects the highest degree first.

When a patient has both internal and external burns/corrosions, the circumstances of admission govern the ●selection of the principal diagnosis (i.e., first-listed diagnosis).

When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or ●respiratory failure, the circumstances of admission govern the selection of the principal diagnosis.

Burns/corrosions of the same local siteClassify burns of the same local site, but of different degrees, to the subcategory identifying the highest degree recorded in the diagnosis.

Non-healing and infected burns/corrosionsNon-healing and necrosis (death) of burned skin should be coded as acute burns. For any infected burn site, use an additional code for the infection.

Assign separate codes for each burn siteWhen coding burns, assign separate codes for each burn site. Category T30, “Burn and corrosion, body region unspecified,” is extremely vague and should rarely be used.

Extent of body surface involved (categories T31, T32)Burns and corrosions classified according to extent of body surface involved should be assigned when the site of the burn is not specified or when there is a need for additional data such as evaluating burn mortality (usually needed by burn units), and when there is mention of a third-degree burn involving 20 percent or more of the body surface.

Categories T31 and T32 are based on the classic “Rule of Nines” in estimating body surface area that has been burned. The Rule of Nines is a system that is based on the rough approximation that each arm has 9 percent of the body’s total skin, the head and neck have 9 percent, each leg 18 percent (two 9s), the front of the torso 18 percent, the back of the torso 18 percent, and the genitalia 1 percent.*

*Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs, or abdomen that involve burns.

continued on next page

October 2012 | Partners in Health UpdateSM 4 www.amerihealth.com/providersOctober 2012 | Partners in Health UpdateSM 4 www.amerihealth.com/providers

ICD-10 Spotlight:Know the codes

CODING CONVENTION: ICD-10 CODING BuRNS AND CORROSIONS (continued)Encounter for treatment of sequela of burns/corrosionsEncounters for the treatment of late effects of burns/corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character “S” for sequela.

Sequela and current burnBurns and corrosions do not heal at the same rate. A current healing wound may still exist with sequela of a healed burn or corrosion. Therefore, when both a current burn and sequela of an old burn exist, both a code for a current burn or corrosion with the 7th character “A” or “D” and a burn or corrosion code with “S” may be assigned on the same record.

Use of external cause code with burns and corrosionsAn external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred.

Example: Burns of the same local site

Same local site Trunk Degree Sequencing

Subcategory Chest Wall 1st degree Secondary diagnosis code

Subcategory Abdominal Wall 2nd degree Principal diagnosis code

For additional information related to the AmeriHealth transition to ICD-10, please visit www.amerihealth.com/icd10. On this site you will also find other examples of how ICD-9 codes will translate to ICD-10 codes in the ICD-10 Spotlight: Know the codes booklet.

HHS announces new ICD-10 compliance date of October 1, 2014On August 24, 2012, the Department of Health and Human Services (HHS) announced its final rule regarding the compliance date for the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10), officially moving it one year from October 1, 2013, to October 1, 2014. All covered entities must comply with ICD-10 by this new date of October 1, 2014.

HHS has adopted this new compliance date in an effort to allow additional time for providers to ensure compliance. AmeriHealth urges you to continue preparing for the transition to ICD-10 by completing an impact assessment

of the ICD-10 transition. AmeriHealth will continue to provide ongoing communication, outreach, and education to providers as the industry prepares for one of the biggest mandated medical data code set initiatives in history.

The final rule can be viewed on the Federal Register’s website at www.ofr.gov/OFRUpload/OFRData/2012-21238_PI.pdf. If you have any questions about the transition to ICD-10, please visit www.amerihealth.com/icd10.

October 2012 | Partners in Health UpdateSM 5 www.amerihealth.com/providers

AdministrAtive

Medicare Part D prescriber prescription verification requests (NJ only)As part of the ongoing effort to combat fraud, waste, and abuse in the Medicare Part D program, the Centers for Medicare & Medicaid Services has engaged NBI MEDIC (Health Integrity LLC), in an outreach effort to request that prescribing physicians verify prescriptions during the course of an investigation.

When investigating a potential prescription drug fraud and abuse situation, a key element includes prescriber prescription verification to confirm whether or not the physician actually wrote the prescription in question. NBI MEDIC routinely mails the prescribing physician a prescription verification form to be completed within two weeks.

NBI MEDIC investigators report that no more than 5 to 10 percent of prescribers respond to these requests. If you are contacted by NBI MEDIC, it is imperative that you respond to their request for prescription verifications within two weeks. A timely and complete response to prescription verification helps NBI MEDIC take appropriate action by confirming or eliminating an allegation of wrongdoing and/or preventing the payment for fraudulent prescriptions.

For information on how AmeriHealth fights fraud, waste, and abuse, visit www.amerihealth.com/antifraud.

PhArmAcy

As new medications become available in the marketplace, we regularly review the prescription drug coverage of our members to make sure they are receiving high quality benefits while minimizing their costs wherever possible.

For those providers who have prescribed Adderall XR you may already be aware there is a generic equivalent available in the marketplace. In most cases, there is a cost savings to members when obtaining a generic. unfortunately, as a result of ongoing supply issues, the generic equivalent for Adderall XR may not be available at the pharmacy. This can lead to delays in filling the medication and may result in higher costs for your patients.

To help alleviate this issue, we are implementing a temporary change to the coverage of Adderall XR for commercial members who have a copay program for their prescription coverage (not a deductible drug plan*). Beginning November 1, 2012, and running through December 31, 2013, brand Adderall XR will be moved

to our formulary’s Tier 1 or generic copayment level. This means that during this time period, if your patients are currently taking the generic equivalent of Adderall XR, brand Adderall XR will be available at the same copayment that they currently pay for the generic version.

Beginning November 1, 2012, your patients’ participating pharmacy will automatically substitute their prescription with brand Adderall XR without an increase in the copayment amount.

If you have any questions about this change in coverage, please call Customer Service at 1-800-275-2583 or your Network Coordinator. *This special limited-time program does not apply to members who have a deductible prescription drug program, discount card plans, or co-insurance plans. For all other members, starting on January 1, 2014, brand Adderall XR will become a non-preferred drug and will move to formulary Tier 3 (highest copay level). Therefore, effective January 1, 2014, to reduce members’ out-of-pocket expense, prescriptions for Adderall XR should be filled with the generic equivalent. Members will continue to pay the same Tier 1 or generic copayment (lowest copay level).

Important change for the coverage of Adderall XR®

October 2012 | Partners in Health UpdateSM 6 www.amerihealth.com/providers

Products

Introducing AmeriHealth 65® Preferred HMOWe are pleased to announce that for 2013, AmeriHealth is introducing AmeriHealth 65 Preferred HMO, an enhanced, affordably priced Medicare Advantage HMO plan. Members receive all the benefits of Original Medicare, plus many more when they use providers in the AmeriHealth New Jersey provider network. The plan is available to the Medicare-eligible population residing in Burlington, Camden, Cumberland, Gloucester, and Salem Counties. The premium for AmeriHealth 65 Preferred HMO is $24.30 for the medical-only plan, and $74.90 for the medical and prescription drug plan. The plan has a $6,700 out-of-pocket maximum for 2013.

AmeriHealth 65 Preferred is an alternative to the AmeriHealth 65 NJ HMO plan, which will be discontinued for individuals only, beginning January 1, 2013. In addition to comprehensive medical coverage and vision, dental, and hearing services, AmeriHealth 65 Preferred features an extensive provider network with more than 3,000 primary care physicians, 50,000 specialist sites, and 100 hospitals, including Philadelphia-area providers.

Members receive access to the SilverSneakers® Fitness Program; preventive care; health resources and wellness programs; and support for managing chronic conditions, such as asthma, diabetes, and chronic obstructive pulmonary disease (COPD).

Medicare Part D prescription drug coverage is optional.

AmeriHealth 65 Preferred HMO benefit highlights

Service Cost to member

Primary care physician (PCP) visits $15 copay per visit

Specialist visits $35 copay per visit

Emergency department $65 copay per visit (not waived if admitted)

urgent care $15 or $35 copay per visit

Outpatient surgery$350 copay (per date of service) for Hospital; $100 copay for Ambulatory Surgical Centers (per date of service)

Inpatient hospital$245 per day for days 1-7 ($1,715 per stay maximum); unlimited days each benefit period

Fitness program SilverSneakers®

Preventive dental $10 every six months exams and cleanings

Eyewear$100 every 2 years ($65 frames, $35 lenses); $40 copay for eye exam every 2 years

Hearing aids and examsup to $500 for hearing aids (two aids) every 3 years; routine hearing exam ($40 every 3 years)

Please contact your Network Coordinator or Hospital/Ancillary Services Coordinator if you have any questions.Limitations, copayments, and restrictions may apply to certain benefits. AmeriHealth 65 Preferred HMO is a Medicare Advantage plan with a Medicare contract and is offered by AmeriHealth HMO, Inc. Prescription benefits are administered by FutureScripts® Secure, a pharmacy benefit management program.

SilverSneakers® is a registered mark of Healthways, Inc.

October 2012 | Partners in Health UpdateSM 7 www.amerihealth.com/providers

medicAl

Policy notifications posted as of September 21, 2012All policies are posted prior to their effective date. Below is a listing of the policy notifications that we have posted to our website as of September 21, 2012.

Policy effective date Policy No. Notification title Notification issue date

September 28, 2012 06.02.17cSerodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test

August 29, 2012

September 28, 2012 11.01.07a Cataract Surgery August 29, 2012

September 28, 2012 08.01.04b Preventive Immunization August 29, 2012

September 28, 2012 08.00.08eRadioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®)

August 29, 2012

September 28, 2012 08.00.44k Zoledronic Acid (Zometa®, Reclast®) August 29, 2012

October 1, 2012 09.00.28b Magnetic Resonance Spectroscopy (MRS) August 31, 2012

October 1, 2012 12.01.01o Experimental/Investigational Services June 29, 2012

October 3, 2012 07.13.05fPhotodynamic Therapy (PDT) using Verteporfin (Visudyne®)

July 3, 2012

October 10, 2012 05.00.24iInterstitial Continuous Glucose Monitoring Systems (CGMSs)

September 10, 2012

October 10, 2012 06.02.32aMultigene Expression Assays for Predicting Recurrence in Colon Cancer

September 10, 2012

October 10, 2012 12.04.02c Nonemergency Ambulance Transport Services September 12, 2012

October 30, 2012 11.14.07iIntra-articular Injection of Hyaluronan for the Treatment of Osteoarthritis

August 1, 2012

December 12, 2012 11.00.06dTreatment of Obstructive Sleep Apnea (OSA) and Primary Snoring for Adults

September 13, 2012

To view the policy notifications, go to www.amerihealth.com/medpolicy, select Accept and Go to Medical Policy Online, and click on the Policy Notifications box. You can also view policy notifications using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Once these policies are in effect, they will be available by using the Search box on the Medical Policy homepage. Be sure to check back often, as the site is updated frequently.

October 2012 | Partners in Health UpdateSM 8 www.amerihealth.com/providers

medicAl

New prior authorization requirements for AmeriHealth 65® NJ HMO and AmeriHealth 65® Preferred HMO members effective January 1, 2013Effective for dates of service on or after January 1, 2013, providers will need to obtain prior authorization for AmeriHealth 65 NJ HMO and AmeriHealth 65 Preferred HMO members for cardiac radiology services, which include:

stress echocardiography ●resting transthoracic echocardiography ●transesophageal echocardiography ●

Specific CPT® codes to which the prior authorization applies are listed in the table below:

Echocardiography service CPT® code Description

Stress echocardiography (SE)93350 Transthoracic stress echo, complete

93351 Transthoracic stress echo, complete w/cont EKG

Resting transthoracic echocardiography (TTE)

93303 Transthoracic echo cardiac anomalies

93304 Transthoracic echo cardiac anomalies, limited

93306 Transthoracic echo complete w/color & spectral

93307 Transthoracic echo complete w/o color & spectral

93308 Transthoracic echo limited

Transesophageal echocardiography (TEE)

93312 Transesophageal echo

93313 Transesophageal echo probe only

93314 Transesophageal echo interpretation

93315 Transesophageal echo congenital

93316 Transesophageal echo congenital, probe only

93317 Transesophageal echo congenital interpretation

Add-on codes

93320* Doppler echo complete

93321* Doppler echo limited

93325* Doppler echo flow velocity

93352* Echo contrast agent (SE only)*Denotes a CPT code that is an add-on/secondary code to the primary code and does not require AIM review.

This change is being made to align Medicare Advantage HMO prior authorization requirements to those already in place for AmeriHealth New Jersey commercial members.

It is very important that providers use the NaviNet® web portal to verify member-specific requirements or refer to the precertification lists on our website. Failure to obtain prior authorization for any of the services or drugs that require it may result in a reduction in payment or nonpayment for the services not authorized.

Please call 1-800-275-2583 if you have any questions about this upcoming change.

October 2012 | Partners in Health UpdateSM 9 www.amerihealth.com/providers

medicAl

Annual Synagis® (palivizumab) distribution programWe are pleased to announce the Synagis® (palivizumab) distribution program for the 2012-2013 respiratory syncytial virus (RSV) season, which is November through April in the united States. RSV is the most common cause of bronchiolitis and pneumonia among children younger than 1.

During the RSV season, we will approve the monthly administration of Synagis® (palivizumab) for at-risk children younger than 2 years of age. Synagis® (palivizumab) is a humanized monoclonal antibody that provides passive immunity against RSV. It is intended to decrease the morbidity and mortality associated with RSV lower respiratory tract disease in at-risk children. At-risk children include those with one of the following conditions or risk factors:

chronic lung disease of prematurity (CLD, formerly ●called bronchopulmonary dysplasia);

history of preterm birth (< 35 weeks 0 days gestation); ●congenital heart disease; ●severe neuromuscular disease; ●congenital abnormalities of the airway. ●

Recommendations for premature infantsSpecific recommendations have been made to reduce the risk of RSV hospitalization for infants who are born at 32 through less than 35 weeks gestation (defined as 32 weeks 0 days through 34 weeks 6 days). Synagis® (palivizumab) prophylaxis should be limited to these infants who are at greatest risk of hospitalization due to RSV. This includes at-risk infants who are younger than 3 months and 0 days (less than 90 days) at the start of the RSV season, as well as those who are born during the RSV season and are likely to have an increased risk of exposure to RSV.

Epidemiologic data suggests that RSV infection is more likely to occur and lead to hospitalization for infants in this gestational age group when at least one of the following risk factors is present:

The infant attends child care (defined as a home or ●facility where care is also provided for any number of infants or young toddlers in the same facility).

The infant has a sibling younger than 5. ●

Prophylaxis may be considered for infants born at 32 to less than 35 weeks gestation whose chronological age is less than 3 months before the onset or during RSV season, and for whom at least one of the above factors is present. Infants in this gestational age category should

receive prophylaxis only until they reach 3 months of age. In addition, these infants should receive a maximum of three monthly doses; many will receive only one or two doses until they reach 3 months of age.

Once an infant has passed 3 months of age (older than 90 days), the risk of hospitalization attributable to RSV lower respiratory tract disease is reduced. Administration of Synagis® (palivizumab) is not recommended after 3 months of age. This criterion for premature infants is based on guidelines published in the 2009 American Academy of Pediatrics (AAP) Red Book®.

How to obtain Synagis® (palivizumab) for use in your officeSynagis® (palivizumab) is covered under the member’s medical benefits. For the 2012-2013 RSV season, it is mandatory for all participating providers to obtain Synagis® (palivizumab) through ACRO Pharmaceutical Services. AmeriHealth will coordinate with ACRO Pharmaceutical Services to facilitate delivery of Synagis® (palivizumab) to your office.

Note: MedImmune, LLC, the makers of Synagis® (palivizumab), has a voluntary program called RSV Connection™. However, AmeriHealth does not participate in this program. All requests for Synagis® (palivizumab) should be sent directly to ACRO Pharmaceutical Services.

continued on next page

medicAl

Guidelines for ordering Synagis® (palivizumab)The following guidelines apply when ordering Synagis® (palivizumab):

Synagis ● ® (palivizumab) will generally be approved for office administration only, unless a patient is receiving home nursing services for a separate indication.

The RSV Enrollment Form must include sufficient ●clinical information to meet our Synagis® (palivizumab) medical policy criteria, which is based on AAP recommendations.

The RSV Enrollment Form can be obtained by ●contacting ACRO Pharmaceutical Services at 1-800-906-7798 and should be faxed to 1-877-381-3806.

Tobacco smoke will not be accepted as an ●environmental pollutant. This guideline is based on the indication from the AAP Committee on Infectious Disease that, while at-risk infants should never be exposed to tobacco smoke, passive household exposure to tobacco smoke has not been associated with an increased risk of RSV hospitalization on a consistent basis.

Fee-for-service providers will be reimbursed for ●the Evaluation & Management procedure codes that correspond to the patient’s office visit. Since

AmeriHealth pays ACRO Pharmaceutical Services directly, you neither pay for doses ordered through ACRO Pharmaceutical Services nor receive reimbursement for the actual pharmaceutical.

upon approval of your request, Synagis ● ® (palivizumab) will be shipped to your office monthly during RSV season. Overnight shipping for the 2012-2013 RSV season begins on Tuesday, October 30, 2012, and ends on Monday, April 1, 2013. up to five doses (one shipment every 30 days) will be shipped per patient.

If you have questions about the Synagis® (palivizumab) distribution program, please contact AmeriHealth Customer Service at 1-800-275-2583.

Note: Synagis® (palivizumab) is not effective in the treatment of RSV disease, and it is not approved for this indication. This is not a statement of benefits. Benefits may vary according to state requirements, product line (HMO, PPO, etc.), and/or employer groups. Member coverage can be verified through the NaviNet® web portal or by calling the Provider Automated System at 1-800-275-2583.

Annual Synagis® (palivizumab) distribution program (continued)

October 2012 | Partners in Health UpdateSM 10 www.amerihealth.com/providers

Coverage change for Plan B One Step® (Levonorgestrel, Next Choice®)Effective January 1, 2013, AmeriHealth will apply age restrictions to the corresponding National Drug Codes (NDCs) for Plan B One Step® (Levonorgestrel, Next Choice®). As a result, Plan B One Step® and generic versions will not be covered for women age 17 and older. Claims for women age 17 and older will deny since Plan B One Step® is available over the counter without a prescription, and AmeriHealth prescription drug programs exclude coverage for drugs dispensed without a prescription. This change will not impact other emergency contraception options available by prescription, which will continue to be covered with no cost-sharing as required by the Affordable Care Act. The requirement to cover contraceptives is effective for plan years on or after August 1, 2012.*

To verify eligibility, please use the NaviNet® web portal or call the Provider Automated System at 1-800-275-2573. For additional information, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.*For members with an AmeriHealth prescription drug plan, generic prescription oral contraceptives are covered with no cost-sharing at retail and mail order participating pharmacies. Cost-sharing applies to brand and non-formulary prescriptions. For customers who are eligible for a temporary safe harbor, the effective date for contraceptive services is for plan years on or after August 1, 2013. If a customer is a “religious employer” as defined by the interim final rules issued by the Departments of Health and Human Services, Labor, and Treasury, they may be exempt from the requirement of providing contraceptive coverage in their medical and/or prescription drug plans.

The Centers for Disease Control and Prevention (CDC) has reported that the nation is on track for record rates of whooping cough cases. Twice as many cases have been reported so far in 2012 as at the same point last year, said a CDC official.1

As a result, the CDC is urging pregnant women and anyone else likely to come into contact with young babies under 12 months of age to get booster shots to prevent whooping cough, even if they have been vaccinated in the past. That’s because babies are most likely to die or be hospitalized when they get the highly contagious bacterial disease. All of the whooping cough fatalities that have occurred so far this year have been among babies who were too young to be fully vaccinated, and more than half of children diagnosed with whooping cough before their first birthday require hospitalization.1

Vaccination recommendationsFor children, the whooping cough vaccine (DTaP) is given in five doses, with the starting dose recommended at 2 months of age and the last dose recommended between the ages of 4 – 6 years.

Compared to children who are fully vaccinated, unvaccinated children have eight times the risk for getting whooping cough, according to the CDC. When vaccinated children do come down with the disease, they tend to have milder symptoms and are less likely to pass their infection onto others.

A booster tetanus, diphtheria toxoids, and acellular pertussis (Tdap) vaccine is available, but only about 8 percent of adults have gotten it, says a CDC representative. The CDC recommends that adults, particularly pregnant women and anyone who comes into contact with babies, get the vaccine. The Tdap booster can be given to adults ages 19 – 64 who have not received Tdap previously. Pregnant women should wait until their third trimester. If not given during pregnancy, then the dose should be given in the hospital after delivery, before the patient is discharged, or as soon as possible in the office.

AmeriHealth members are covered for whooping cough vaccinationsBoth primary care providers and obstetricians will be reimbursed for the whooping cough vaccine for AmeriHealth members. We encourage you to give this vaccine to your patients, particularly to pregnant women and others who will be in contact with babies.

We hope our members understand that by getting vaccinated, they can help to reduce the likelihood of spreading whooping cough to vulnerable populations, like young babies.

1WebMD Health News. Boyles, S. Whooping cough heading to a 50-year high. http://children.webmd.com/news/20120719/cdc-whooping-cough-heading-to-5-decade-high. Accessed July 30, 2012.

Members encouraged to get whooping cough vaccine to combat rising rates

heAlth And Wellness

October 2012 | Partners in Health UpdateSM 11 www.amerihealth.com/providers

October 2012 | Partners in Health UpdateSM 12 www.amerihealth.com/providers

We encourage our members to get vaccinated against the seasonal flu and ask that you advise your patients to receive a vaccination as soon as possible.

The recommendations for the 2012-2013 flu season from the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices include flu vaccination for all people 6 months and older, especially pregnant women, adults 65 and older, and anyone with a chronic illness.

For more information about this year’s flu vaccine, visit the CDC’s flu website at www.cdc.gov/flu.

For detailed information on our coverage of the influenza vaccine for 2012-2013, please read the article posted on our Medical Policy website under News and Announcements at www.amerihealth.com/medpolicy.

Seasonal flu vaccine recommendations

heAlth And Wellness

Case management Help for your patients when they need it

Sometimes members need extra support. Registered nurse case managers from AmeriHealth are available to provide telephone support and information to your patients who are experiencing complex health issues or are facing challenges in meeting health care goals. Consider making a referral to case management if any of your patients need help with the following:

The case manager will work with your office to find out how best to support the member in following your treatment plan.

To refer a patient to case management, call 1-800-313-8628, or complete an online referral form at www.amerihealth.com/case_mgmt_ref_form.

w wound carew cancer treatment educationw complications of pregnancyw adherence to treatment planw community resource information

w coordination of home care servicesw complex pediatric medical conditionsw socioeconomic support (medications)w investigation of benefits for medical equipmentw chronic condition with multiple comorbid conditions

I m p o r t a n t r e s o u r c e s

Visit our website: www.amerihealth.com/pnc

AmeriHealth Direct Ship Injectable Program (medical benefits) www.amerihealth.com/directship

Anti-Fraud and Corporate Compliance Hotline 1-866-282-2707

www.amerihealth.com/antifraud

Care Management and Coordination Case Management 1-800-313-8628

Baby FootSteps® 215-241-21981-800-598-2229

ConnectionsSM Health Management Programs ConnectionsSM Health Management Program Provider Support Line 1-866-866-4694

ConnectionsSM Complex Care Management Program 1-800-313-8628

ConnectionsSM Provider Portal

Credentialing Credentialing Violation Hotline

215-988-1413www.amerihealth.com/credentials

Credentialing and recredentialing inquiries (NJ only) 1-866-227-2186

Customer Service/Provider Services Provider Automated System (eligibility/claims status/referrals) Connections Health Management Programs Precertification/maternity requests — Imaging services (PA and DE only) (CT, MRI/MRA, PET,

and nuclear cardiology) — Authorizations

1-800-275-2583

Provider Services user guide

eBusiness Help Desk 215-241-2305

FutureScripts® (pharmacy benefits) Prescription drug prior authorization Fax

1-888-678-70121-888-671-5285

Direct Ship Specialty Pharmacy Program Fax

1-888-678-70121-888-671-5285

Mail order program toll-free fax 1-877-228-6162

Blood Glucose Meter Hotline 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.amerihealth.com/rx

FutureScripts® Secure (Medicare Part D) 1-888-678-7015

Formulary updates www.amerihealthmedicare.com

Mail order program toll-free fax 1-877-344-1318

Imaging services (NJ only) (CT, MRI/MRA, PET, and nuclear cardiology) 1-800-859-5288

Medical Policy website www.amerihealth.com/medpolicy

NaviNet® portal registration www.navinet.net

Provider Supply Line 1-800-858-4728

www.amerihealth.com/providerautomatedsystem

www.amerihealth.com/providersupplyline

AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • QCC Insurance Company d/b/a AmeriHealth Insurance Company

www.hdproviderportal.com/amerihealth