par tners health update€¦ · upda te 3 march 2004 billing reminders: 10-digit hmo provider id...

P A R T N E R S

Health in

W O R K I N G T O G E T H E R F O R Q U A L I T Y H E A L T H C A R E

U P D A T Ewww.amerihealth.com

To support market demand, AmeriHealth is pleased toannounce the introduction in Delaware of AmeriHealthFlex Programs, the new HMO, POS, and PPO benefitoptions for group employers, effective April 1, 2004. *These programs are designed to provide affordable healthcare coverage to our customers. AmeriHealth Flex Programs feature consistency across product lines in

* Pending regulatory approval.

copayments, benefit maximums, and precertificationrequirements. AmeriHealth Flex Program members inDelaware can be easily identified by the “FLEX” andstate indicators on their ID cards. Please refer to theAmeriHealth Flex Programs enclosure for more details,or contact Provider Services or your Network Coordinator with any questions about the new AmeriHealth Flex Programs.

Introducing AmeriHealth Flex Programs Benefit Options forDelaware Available April 1, 2004

March 2004

INSIDE THIS ISSUE

UPDATES: BILLING REMINDERS:

• “Do It All” with NaviNetSM and NaviNet ClaimsSM

• Preventing False Claims

• Keeping Provider Information Current

• Credentialing Compliance Hotline and Web Page

• HIPAA-Compliant Transactions

• 10-Digit HMO Provider ID Number and Performing Provider ID Number

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Important Reminder Regarding: Information for Converting to HIPAA-Compliant Transactions

As a reminder, the mandated HIPAA Transactions and Code Sets compliance date was October 16, 2003.We applaud those providers who have achieved compliance, and those providers whose efforts are nearing completion.

For providers who have not achieved HIPAA transaction compliance, we will continue to make testingopportunities available. You may contact the NaviMedix®, Inc. HIPAA Conversion Team at (866) 877-6284 for assistance with testing and converting to the HIPAA-compliant 837 claims transaction.

Important note for providers who submit electronic claims through Highmark®:

Providers who have not yet converted to the HIPAA-compliant 837 claims transaction and are currentlysubmitting electronic claims to Highmark® must complete a new enrollment application before being able to testfor conversion. To enroll, please visit the Highmark® EDI Sign-Up Web page athttps://www.highmark.com/health/professionals/edi-services/edi_signup.html. Once there, click on the linktitled “EDI Transaction Application (Claims & Inquiry).” Once you submit the completed enrollmentform, NaviMedix®, Inc. will notify you to begin testing.

For more information about HIPAA-compliant electronic transactions, please visit our Electronic DataInterchange (EDI) Services Web page at www.amerihealth.com/edi.

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Billing Tips

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Billing Reminders:10-Digit HMO Provider ID Number and PerformingProvider ID Number (PIN #) Required PLEASE SHARE THIS IMPORTANT BILLING INFORMATION WITH YOUR BILLING VENDOR

As previously communicated, effective January 1, 2003, the 10-digit HMO provider ID number isrequired on all HMO claims submissions, encounters, referrals, and related correspondence. HMO claimssubmitted without the 10-digit HMO provider ID number are being rejected as non-clean claims. Bothyour group provider ID number and the Performing Provider ID Number (PIN #) need to reflect the new10-digit numbers.

The Performing Provider ID Number must be recorded on all claims. This is a required data element inconjunction with HIPAA compliance and other requirements. HMO, POS, and PPO claims submittedwithout the identification number of the physician or other professional provider performing the procedureor service are being rejected and returned as non-clean claims and must be resubmitted with the necessaryinformation. The Performing Provider ID Number should be reported in section 33 of the CMS 1500claim form in the “PIN #” field.

When submitting HIPAA-compliant electronic claims through Electronic Data Interchange (EDI) transmission, the Performing Provider ID Number should be entered in the rendering provider ID numberfield, located in the REF02 data element, either in loop 2310B (at the claim level) or loop 2420A (at theline level). The referring physician’s provider ID number should be reported in the 2310A loop in theREF02 data element. The applicable group provider ID number should be reported in the secondary billingprovider segment, located in the REF02 data element, in loop 2010AA. For more information on EDItransmission of electronic claims, please consult the 837P HIPAA Transaction Companion Guide on ourWeb site at www.amerihealth.com/edi.

As always, the provider ID numbers entered on electronic and paper-based claims should directly reflect themember’s benefit plan. Please enter your 10-digit HMO provider ID number on all HMO and POS(referred and self-referred) claims submissions, encounters, referrals, and related correspondence. Enteryour PPO provider ID number on all PPO claims and related correspondence.

Please note the following:• The requirements above apply to paper and electronic claims submissions.• With the October 27, 2003 transition of POS self-referred claims processing to MHS, our managed

care information system, you should enter your 10-digit HMO provider ID number on all POS claims(referred and self-referred).

• The updated EDI electronic claims instructions outlined above are compliant with HIPAA Transaction and Code Set rules, which require a transition from the National Standard Format (NSF)to the HIPAA 837P transaction when submitting electronic claims. The compliance deadline forHIPAA Transactions and Code Sets was October 16, 2003. For testing and conversion assistance tothe HIPAA-compliant claims transaction (837), please contact the NaviMedix®, Inc. HIPAA Conversion Team at (866) 877-6284.

Important note for providers who submit electronic claims through Highmark®: If you have not yetconverted to the HIPAA-compliant 837 claims transaction, you must complete a new enrollmentapplication at https://www.highmark.com/health/professionals/edi-services/edi_signup.html before beingable to test for conversion.

• The provider ID numbers that you currently use for AmeriHealth PPO services are not affected andcontinue to be valid for AmeriHealth PPO claims and related correspondence.

• Physical therapists and labs which have not been assigned a specific Performing Provider ID Numbershould submit their group provider ID number in both the “Grp #” and “PIN #” fields of box 33 onthe CMS 1500 form. When submitting electronic claims, physical therapists and labs that have notbeen assigned a specific Performing Provider ID Number should report their group provider ID number in both the 2010AA loop and either the 2310B loop (at the claim level) or 2420A loop(at the line level) in the REF02 data element. Claims submitted without information in both of these fields are now being rejected as non-clean claims and must be resubmitted with the necessary information.

Billing Tips continued

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“Do It All” with NaviNetSM:Featuring Information on the Preauthorization Feature

Streamline the daily administrative tasks associated with your patients’ health care with NaviNetSM, theHIPAA-compliant Web-based connectivity solution offered by NaviMedix®, Inc. NaviNetSM enables youroffice to connect with our back-end systems to reduce time and costs associated with health care administration.

NaviNetSM features include, but are not limited to: Member Eligibility and Benefits Inquiry, Referral Submission, Referral Inquiry, Encounter Submission, Claims Status Inquiry, Drug Preauthorization Submission, Procedure and Diagnosis Code Inquiry, Emergent Admission (ER), and the Provider Change Form.

Specialists, in particular, use the NaviNetSM Preauthorization Submission feature to request precertificationfor procedures to be performed at an acute care facility or ambulatory surgical center. Regardless of themethod used for preauthorization submission, Primary Care Physicians (PCPs), the precertifying specialist,and the facility where the service is to take place may retrieve preauthorization records using the NaviNetSM

Authorization Status Inquiry feature. When applicable, the date of admission or service may be changedfor approved authorizations in the Authorization Status Inquiry Transaction Detail screen.

This method of electronic submission reduces call volume and speeds the precertification process,contributing to improved provider satisfaction. We encourage you to consider the advantages of this comprehensive application.

Improve Claims and Encounter Submission With NaviNet ClaimsSM

With NaviNet ClaimsSM, offered by NaviMedix®, Inc., network providers may submit HMO, PPO, andPOS claims and encounters to AmeriHealth electronically, free of charge. In addition to converting allnon-HIPAA-compliant claims to HIPAA-compliant versions, submission through NaviNet ClaimsSM issimple and helps minimize claims rejections.

NaviNet ClaimsSM can work with a provider’s practice management system or can be supplied as desktopsoftware for use with a PC and a modem or Internet access.

Editing features allow for fast and simple correction of errors before claims are submitted, resulting inreduced payer rejections and administrative concerns. Reporting features enable claims to be tracked fromthe moment of submission through receipt by the health plan.

Investors in NaviMedix®, Inc. include an affiliate of AmeriHealth, which has a minority ownership interest in NaviMedix®, Inc.

Get Connected

NAVINETSM REGISTRATION OR QUESTIONS:

eCommerce Provider Inquiry Line (856) 638-2701 in New Jersey; (302) 661-6111 in Delawareor, complete our Online Inquiry Form at www.amerihealth.com/providers.

TECHNICAL ASSISTANCE FOR EXISTING NAVINETSM USERS:

NaviMedix®, Inc. (888) 482-8057, 8:00 A.M. to 8:00 P.M., EST, Monday through Friday, and 8:00 A.M. to 3:00 P.M., EST, Saturday

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Preventing False Claims Procedures

Every year, tens of millions of medical claims are received, processed, and paid appropriately. Althoughthe vast majority of providers render appropriate care and bill accordingly, there are unfortunately a fewproviders who abuse the billing process.

The Corporate and Financial Investigations Department (CFID), which is charged with the prevention,detection, and investigation of all potential areas of fraud and abuse, has state-of-the-art software that itused to identify potential aberrant billing patterns. The software runs against a database, which containsall medical, facility, and pharmacy claims. The database also includes all member enrollment and providerinformation. The software compares claims submitted by providers against their respective specialtygroup and looks for irregularities in billing patterns. It provides a broad-based historical view of providerpatterns using rules based on provider utilization, financial profiles, and documentation of high-impact,consistently egregious activity.

This technology identifies providers who warrant immediate attention based on claims that are aberrantcompared to past or “typical” experience, established thresholds or norms. The software also comparesproviders’ billing patterns to those of their peers.

This early-warning detection has given the CFID the opportunity to investigate much sooner than the traditional retrospective approach, thus enabling us to recover payments on claims more quickly and prevent erroneous payments in the future. In 2003, the CFID recovered over $25.2 million in overpaidclaims and referred 38 fraud cases to law enforcement authorities. Twenty-five individuals were indictedand 17 plead guilty or were convicted and subsequently sentenced.

The CFID has had success utilizing this sophisticated software, but there is no substitute for providers’vigilance. If you suspect any health care-related fraud activity, please call our toll-free Anti-Fraud andCorporate Compliance Hotline at (866) 282-2707, or visit our Web site at www.amerihealth.com/anti-fraud.

Keeping Provider Information Current

It is important that our provider information files are accurate and up-to-date in order to give you qualityservice. Please call Provider Services, your Network Coordinator, or fax the Provider Change form (foundin your Provider Manual) to notify us of changes to your office information. If a change also represents achange to your W-9 Form (new name, new tax ID number, new billing vendor or “pay to” address, newownership), a physician’s signature and the W-9 Form must be provided. The Provider Change Form andany accompanying documents can be faxed to Network Administration at (215) 988-6085.

Be sure to retain the transmission confirmation from your fax machine. Forms may also be mailed to:

Policies

Network AdministrationAmeriHealthP.O. Box 41431Philadelphia, PA 19101-1431

AmeriHealth products are offered by QCC Insurance Company d/b/a AmeriHealth Insurance Company, AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey.

The third-party Web sites 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 ofproducts or services provided by or advertised in these third-party sites. URLs presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefit plans. Members should refer to their benefit contract for complete details of the terms, limitations, and exclusions of their coverage.

IMPORTANT RESOURCES

009189 2003-0269 12/03

PROVIDER INFORMATION andTOOLS WEB PAGEwww.amerihealth.com/providers

PROVIDER CLINICAL PRACTICEGUIDELINES WEB PAGE www.amerihealth.com/guidelines

PROVIDER MEDICAL POLICY WEB PAGEwww.amerihealth.com/medpolicy

PROVIDER ELECTRONIC DATAINTERCHANGE SERVICESWEB PAGEwww.amerihealth.com/edi

CORPORATE AND FINANCIALINVESTIGATIONS DEPARTMENTAnti-Fraud and Corporate Compliance Hotline(866) 282-2707www.amerihealth.com/anti-fraud

CREDENTIALING COMPLIANCEHOTLINE (866) 282-2707www.amerihealth.com/credentials

PROVIDER SERVICES

Policies/Procedures/Claims

HMO

(800) 821-9412 NJ(800) 888-8211 DE

PPO(800) 595-3627

PHARMACY SERVICES Prescription Drug Authorization(888) 671-5280

Toll-Free Fax(888) 671-5285

Direct Ship Injectable(267) 402-1711(888) 671-5280

Fax(215) 761-9165

Blood Glucose Meter HotLine(888) 494-8213 (option 2)

HEALTH RESOURCE CENTERAmeriHealth Healthy LifestylesSM

(800) 275-2583

Precertification(800) 227-3116

CARE MANAGEMENT AND COORDINATION (formerly PatientCare Management)

HMO Commercial(800) 888-8211 DE(800) 227-3116 NJ

PPO(800) 373-4455

Case Management/Ancillary(800) 373-4455 DE(800) 332-2566 NJ

PROVIDER SUPPLY LINE(800) 858-4728

The AmeriHealth Partners in HealthMonthly Update is a publication of theProvider Communications departmentfor the exchange of information and ideas among the Amerihealth Provider community. Suggestions are welcome.

Contact Information:

Henna RemsteinManaging Editor

Maalek MarshallEditor

Elizabeth DeragoProduction Coordinator

Provider CommunicationsAmeriHealth1901 Market Street, 35th FloorPhiladelphia, PA 19103

Visit our Web site atwww.amerihealth.com

Policies continued

Credentialing Compliance Hotline and Web Page

Our provider credentialing policy requires that our members receive health care services only from fully credentialed practitioners. As noted in your Professional Provider Agreement, non-credentialed practitioners may not see our members on anin-network basis. Therefore, we need your assistance in identifying credentialing noncompliance.

If you suspect any violations of our practitioner credentialing policies, please proceed with one of the following options:

1. Call the confidential Credentialing Corporate Compliance Hotline toll-free at (866) 282-2707.

2. Submit an online Credentialing Noncompliance Referral Form available at www.amerihealth.com/credentials.

*HMO/POS Flex Programs pending regulatory approval. Provider Communications (Rev. 2/04)

QCC Insurance Company d/b/a AmeriHealth Insurance Company � AmeriHealth HMO, Inc.

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Announcing New AmeriHealth Flex Programs for HMO, POS, and PPO* To support market demand, AmeriHealth is pleased to announce the introduction of AmeriHealth FlexPrograms, new HMO, POS, and PPO benefit programs available for group employers in Delawareeffective April 1, 2004. * These programs are designed to provide affordable health care coverage to ourcustomers. Groups can develop comprehensive HMO/POS/PPO benefit programs by selecting differentoptions from the following components: Outpatient/Office Visit Care (C), Facility/Ancillary Care (F),and, if purchasing a PPO or POS product, an Out-of-Network Component (O). AmeriHealth FlexPrograms feature consistency across product lines in copayments, benefit maximums, and precertificationrequirements. We have included the following reference documents for your use when working withmembers who have AmeriHealth Flex Programs benefits:

� Sample AmeriHealth Flex Programs ID Cards.� AmeriHealth Flex Programs Benefit Guide.� AmeriHealth Flex Programs Copayment Chart.� AmeriHealth Flex Programs Precertification Requirements.� AmeriHealth Flex Programs Biotech/Specialty Injectables List.� AmeriHealth Flex Programs Injectable Request Form.

Contact Provider Services or your Network Coordinator with any questions about the new AmeriHealthFlex Programs.

For more detailed information on the AmeriHealth Flex Programs, please refer to the next AmeriHealthProvider Manual update, available later this year.

Highlights of Changes Affecting Professional ProvidersAmeriHealth Flex Programs create consistency across product lines in copayment application. However,there are differences between the AmeriHealth Flex Programs and existing product offerings. Thesechanges are summarized below:

The PCP copayment applies to General Practice, Family Practice, Internal Medicine, Pediatrician,Obstetrician, Gynecologist, and Midwife Office Services.

There are two levels of member cost-sharing for radiology services provided in an outpatientfacility: Routine and Complex.

Routine radiology/diagnostic services have a lower copayment. Complex services, MRI/MRA, CT scans,and PET scans*, have a higher copayment.

The applicable copayments are shown on the member’s identification card following the SD indicator(SD = Specialty/Diagnostic Copayment).

SD $20/$40 = $20 Routine Radiology/ $40 MRI/MRA, CT scans, PET scans SD $30/$60 = $30 Routine Radiology/ $60 MRI/MRA, CT scans, PET scansSD $40/$80 = $40 Routine Radiology/ $80 MRI/MRA, CT scans, PET scans*Copayments for routine radiology and complex radiology services are applied once per date of service,per provider, but are not applied in an inpatient setting, a physician’s office, or the Emergency Room. Ifboth a routine and a complex radiology service are provided on the same day, then two copayments areapplied.



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There are two levels of member cost-sharing that apply to injectable medications: Standardoffice-based injectables and Biotech/Specialty injectables

Standard office-based injectables, such as antibiotics and steroids, will continue without a copayment.

Biotech/Specialty injectables shown on the enclosed list must be obtained through the Direct Shippharmacy program. Do not collect a copayment for Biotech/Specialty injectables ordered through theDirect Ship Injectable Unit. The injectable vendor will bill the member for their Biotech/Specialtyinjectable copayment.

Biotech/Specialty injectables provided in the physician’s office from a physician’s supply are subject tothe Biotech/Specialty copayment described in the member’s benefits. You must notify the Direct ShipInjectable Unit of Pharmacy Services prior to the administration of any Biotech/Specialty injectable.Precertification is required for the listed Biotech/Specialty injectables.

Durable Medical Equipment and Prosthetics: There is added member cost-sharing. Coinsurance applies to all DME and prosthetics, including servicesprovided in a physician’s office.

A copayment chart, which also includes in-network coinsurance information, for the AmeriHealth FlexPrograms is enclosed for your reference.

New Precertification RequirementsPrecertification requirements are consistent across product lines for HMO, POS, and PPO AmeriHealthFlex Programs; however, the list of services that require precertification has been changed from our otherprograms (see enclosure). The enclosed precertification list applies to the AmeriHealth Flex Programsonly.

For HMO and POS members, there has been a change in the way benefit limits are structured for PhysicalTherapy, Occupational Therapy, and Speech Therapy. For AmeriHealth Flex products, physical andoccupational therapy benefits are now limited to a specific number of visits (30) received at any timethroughout the calendar year. In non-Flex products, these benefits are limited to a certain number of visitswithin a consecutive 60-day period. Speech therapy in the AmeriHealth Flex Programs is limited to 20visits per calendar year. New ID CardsAmeriHealth Flex Programs members will carry identification cards that clearly indicate the member isenrolled in an AmeriHealth Flex Programs option. On the member’s identification card, you will see aline of text that identifies the product, the office, outpatient care benefit options (C1, C2, or C3), thefacility/ancillary benefit options (F1, F2, F3, or F4), and for PPO/POS members, the out-of-networkbenefit options (O1 or O2). These codes correlate to the benefit options shown on the enclosed BenefitGuide. For example, if the member’s identification card indicates FLEX PPO C1, F3, O2, then themember is enrolled in an AmeriHealth Flex Programs PPO option. The member’s benefit levels areshown in the Benefit Guide as follows:C1 Indicates that the benefits shown in Column 1 of the Office/Outpatient Care section of the Benefit

Guide apply.F3 Indicates that the Facility/Ancillary benefits shown in Column 3 of the Facility/Ancillary section

of the Benefit Guide apply.O2 Indicates that the Out-of-Network benefits shown in Column 2 of the Out-of-Network section of

the Benefit Guide apply.The first Delaware members will be enrolled in the AmeriHealth Flex Programs effective April 1, 2004.*Please call Provider Services with questions regarding the new AmeriHealth Flex Programs.

*HMO/POS Flex Programs pending regulatory approv

QCC Insurance Company

Sample Delaware FLEX PPO ID Card: Copay 1, Facility 1, OON 1*

FLEX PPO C1-F1-O1A. SUBSCRIBERIDENTIFICATION NO. GROUP NO.

Q2B 123456789 12345XPCP $10 SD $20/$40 ER $100

SELRX

PPODE

Sample Delaware FLEX HMO ID Card: Copay 1, Facility 1*

FLEX HMO C1-F1 DE

Sample Delaware FLEX POS ID Card: Copay 2, Facility 2, OON 2*

MEMBE

1234567FAMILY302-555ER$100

DE

MEMBER, C.

123456789 00 QFAMILY PRACTICE ASSOC302-555-5555 PCP$10 SELRXER$100 SD$20/40 RX: APP0000

FLEX POS C2-F2-O2

al. Pro

d/b/a AmeriHealth Insurance Company � Ameri

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R, D.

89 00 Q PRACTICE ASSOC-5555 PCP$20 SELRX SD$30/60 RX: APP0000

vider Communications (Rev. 2/04)

Health HMO, Inc.

OFFICE/OUTPATIENT CARE

Primary Care Office Visit $10 $20 $30OB-GYN Office Visit $10 $20 $30Specialist Office Visit $20 $30 $40Physical and Occupational Therapy $20 $30 $40

30 visits per calendar year (combined with PPO/POS out-of-network/self-referred max)Spinal Manipulations $20 $30 $40

20 visits per calendar year (combined with PPO/POS out-of-network/self-referred max)Speech Therapy $20 $30 $40

20 visits per calendar year (combined with PPO/POS out-of-network/self-referred max)Cardiac Rehab - 36 sessions per calendar year (combined with PPO/POS out-of-network/self-referred max) $20 $30 $40Pulmonary Rehab - 36 sessions per calendar year (combined with PPO/POS out-of-network/self-referred max) $20 $30 $40Orthoptic/Pleoptic Therapy - 8 sessions per lifetime (combined with PPO/POS out-of-network/self-referred max) $20 $30 $40Outpatient Laboratory/Pathology (outpatient facility & lab) $0 $0 $0Outpatient X-Ray/Radiology/Diagnostic Services

Routine Radiology/Diagnostic $20 $30 $40MRI/MRA, CT Scans/PET Scans (pre-authorization required for PET Scans) $40 $60 $80

(No copay applicable when service performed in an ER or office setting)Outpatient Mental Health* $20 $30 $40

20 visits per calendar year (combined with PPO/POS out-of-network/self-referred max)Outpatient Substance Abuse* $20 $30 $40

60 visits per calendar year (combined with PPO/POS out-of-network/self-referred max)120 visits per lifetime (combined with PPO/POS out-of-network/self-referred max)

Outpatient Serious Mental Illness* $20 $30 $40Routine Gyn Exam/Pap (1 per calendar year regardless of age) $10 $20 $30Mammography $0 $0 $0Pediatric Immunizations $0 $0 $0Injectable Medications

Standard injectables (ex. steroids, antibiotics) $0 $0 $0Biotech/Specialty injectables* (Pre-authorization applies) $50 $75 $1000

Maternity 1st Visit $10 $20 $30Chemotherapy/Radiation/Infusion Therapy (pre-authorization required for Infusion Therapy) $0 $0 $0

C1 C2 C3

* Pre-authorization required. AmeriHealth PPO members may be held responsible for financial penalties if they do not pre-authorize services when using an out-of-network provider. AmeriHealth Point-of-Service membersmay be held responsible for financial penalties if they do not pre-authorize inpatient/outpatient services when using their self-referred benefits. Members will be subject to 20% reduction in benefits if prior approval is notobtained for inpatient/outpatient treatment services for PPO out-of-network/POS self-referred care.

This Product Grid is a highlight of benefits available and is provided as a sales document to be used by AmeriHealth sales representatives and those appointed/contracted to sell our products. For specific details, conditionsand exclusions, please refer to the applicable group contracts. As terms/benefit provisions change periodically, please contact your AmeriHealth sales representative to ensure you possess the most current information. ThisProduct Grid is the sole property of AmeriHealth contains confidential and proprietary information. This grid and its contents should not be copied, disclosed, or distributed to any third party/person without the prior writtenpermission of AmeriHealth.

*HMO/POS Flex Programs pending regulatory approval.

QCC Insurance Company d/b/a AmeriHealth Insurance Company, AmeriHealth HMO, Inc. (Rev. 2/04)

AmeriHealth Flex Programs Benefit GuideAmeriHealth PPO, AmeriHealth Point-of-Service and AmeriHealth HMO

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FACILITY/ANCILLARYHospital Inpatient* $0 $100/day $150/day $250/day

Unlimited days in-network/referred Max 5 copays/admission Max 5 copays/admission Max 5 copays/admission

Copay waived for new admissions within 90 days of prior admission (any diagnosis) ($500) ($750) ($1250)

Outpatient Surgery* $0 $50 $75 $125

Anesthesia $0 $0 $0 $0

Surgeon/Assistant Surgeon $0 $0 $0 $0

Skilled Nursing Facility* $0 $50/day $75/day $125/day

120 days per calendar year (combined with PPO/POS out-of-network/self-referred max) Max 5 copays/admission Max 5 copays/admission Max 5 copays/admission

Copay NOT WAIVED if admitted from inpatient hospital stay ($250) ($375) ($625)

Home Health Care* $0 $0 $0 $0

Hospice* $0 $0 $0 $0

Inpatient Mental Health* $100/day $150/day $250/day

30 days per calendar year (combined with PPO/POS out-of-network/self-referred max) $0 Max 5 copays/admission Max 5 copays/admission Max 5 copays/admission

($500) ($750) ($1250)

Inpatient Substance Abuse* $100/day $150/day $250/day

30 days per calendar year (combined with PPO/POS out-of-network/self-referred max) $0 Max 5 copays/admission Max 5 copays/admission Max 5 copays/admission

90 days per lifetime (combined with PPO/POS out-of-network/self-referred max) ($500) ($750) ($1250)

Inpatient Serious Mental Illness* $100/day $150/day $250/day

Unlimited days per calendar year $0 Max 5 copays/admission Max 5 copays/admission Max 5 copays/admission

($500) ($750) ($1250)

Emergency Room (Copay NOT WAIVED, if admitted) $100 $100 $100 $100

Ambulance Transport* (elective non-emergency) $0 $0 $0 $0

Dialysis $0 $0 $0 $0

Outpatient Private Duty Nursing* 90% 90% 85% 85%

360 hours per calendar year (combined with PPO/POS out-of-network/self-referred max)

Durable Medical Equipment* (repairs and replacements over $100 and all rentals) 70% 70% 50% 50%

Prosthetics* (repairs and replacements over $100 and all rentals) 70% 70% 50% 50%

F1 F2 F3 F4

* Pre-authorization required. AmeriHealth PPO members may be held responsible for financial penalties if they do not pre-authorize services when using an out-of-network provider. AmeriHealth Point-of-Service membersmay be held responsible for financial penalties if they do not pre-authorize inpatient/outpatient services when using their self-referred benefits. Members will be subject to 20% reduction in benefits if prior approval is notobtained for inpatient/outpatient treatment services for PPO out-of-network/POS self-referred care.

AmeriHealth Flex Programs Benefit Guide

This Product Grid is a highlight of benefits available and is provided as a sales document to be used by AmeriHealth sales representatives and those appointed/contracted to sell our products. For specific details, conditionsand exclusions, please refer to the applicable group contracts. As terms/benefit provisions change periodically, please contact your AmeriHealth sales representative to ensure you possess the most current information. ThisProduct Grid is the sole property of AmeriHealth contains confidential and proprietary information. This grid and its contents should not be copied, disclosed, or distributed to any third party/person without the prior writtenpermission of AmeriHealth.

*HMO/POS Flex Programs pending regulatory approval. QCC Insurance Company d/b/a AmeriHealth Insurance Company, AmeriHealth HMO, Inc. (Rev. 2/04)

AmeriHealth PPO, AmeriHealth Point-of-Service and AmeriHealth HMO

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AmeriHealth Flex Programs Copayment Policy Summary*Available for group employers in Delaware effective 4/1/04.

Office VisitsGeneral Practice, Family Practice, InternalMedicine, Pediatricians, and OB/GYNs

� Subject to primary care office visit copayment

Specialist Visits � Subject to specialist office visit copaymentAfter Hours Visits � Subject to primary care office visit copaymentHome Visits � Subject to primary care office visit copayment Telephone Consult � Not CoveredSpinal Manipulation � Subject to specialist copayment

� One copayment per date of service per provider when multipleservices are billed

Therapy ServicesSpeech, Cardiac Rehab, Pulmonary Rehab,Orthoptic/Pleoptic

� Subject to specialist copayment

Physical/Occupational � One copayment per date of service per provider when multipleservices are billed

ImmunizationsAt time of physician office visit

� Copayment applies to office visit, not the immunizationOutpatient Lab/PathologyAt time of physician office visit

� Copayment applies to office visit, not outpatient lab/pathologyOutpatient facility & lab � No copaymentRoutine Radiology/X-Ray/Diagnostic ServicesOutpatient department of a hospital orfreestanding radiology site

� One copayment per date of service per provider when multipleservices are billed

Office Setting � No copaymentEmergency Room � No copaymentComplex Radiology ServicesMRI/MRA, CT & PET ScansOutpatient department of a hospital orfreestanding radiology site

� Higher specialist copayment taken for complex radiologyservices; member’s plan design determines applicablecopayment

Emergency Room � No copaymentMammogram (Routine andDiagnostic)

� No copayment

Allergy InjectionsAt time of physician office visit

� No copayment

Provided w/o physician office visit � No copaymentAdministered by nurse, technician � No copaymentStandard Injectables Administered by physician at time of officevisit

� Copayment applies to office visit, not injectable

Note:� When the copayment is greater than the allowable amount, only the allowable amount should be collected from the

member. In the event the copayment is collected and the practice subsequently determines the allowable amount is lessthan the copayment, then the difference between the allowable amount and the copayment must be refunded to themember.



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AmeriHealth Flex Programs Copayment Policy Summary*Available for group employers in Delaware effective 4/1/04.

Biotech/Specialty Injectables -Office-based or Self-Administered

� Subject to applicable Biotech/Specialty injectable copayment� Subject to office visit copayment

Office Based Surgery � Copayment subject to the office visit, not the surgery

Surgery in the ER � ER copayment applies

Post Surgical Visits � Not subject to office visit copayment within the post-operativeperiod as determined by Medicare

Routine GYN Visits � Subject to primary care office visit copaymentNon-Routine GYN Visits � Subject to primary care office visit copaymentRoutine Obstetrical VisitsFirst Obstetrical Visit

� Subject to primary care office visit copaymentSubsequent Obstetrical Visits � No copaymentDME � Subject to coinsurance as determined by member’s benefitsEmergency Room � Copayment not waived when member is admitted to inpatient

from an ER setting� When surgery and radiology services are provided as part of an

ER visit, member is responsible for ER copay onlyHospital Inpatient (includes acutecare hospitals, rehabilitationhospitals, mental health andsubstance abuse treatment facilities)

� Copayment per day, up to 5 copayments per admission� Copayment waived for new admissions within 90 days of prior

admission, regardless of diagnosis� Copayment only waived once member has met any copayment

maximumsMaternity Admissions � Copayment per day, up to 5 copayments per admission

� One copayment applies per day, when mother/baby reported onthe same claim for the same date of service

� One copayment applies per day, when mother/baby reported ontwo separate claims for the same dates of service

Skilled Nursing Facility � Copayment applies whether member is admitted directly to SNFor admitted from hospital

� Copayment is different than Inpatient Hospital copayment;amount determined by member’s benefits

Outpatient Surgery Outpatient hospital � One copayment per date of service per providerBirth center � One copayment per date of service per providerAmbulatory surgi-center � One copayment per date of service per providerER Setting � ER copayment appliesOffice Setting � Office visit copayment applies

Note:� When the copayment is greater than the allowable amount, only the allowable amount should be collected from the

member. In the event the copayment is collected and the practice subsequently determines the allowable amount is lessthan the copayment, then the difference between the allowable amount and the copayment must be refunded to themember.



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AMERIHEALTH FLEX PROGRAMS HMO, POS, PPO PRECERTIFICATIONREQUIREMENTS*

All AmeriHealth Flex Programs options require precert regardless if in- or out-of-network, referred, or self-referred.

Inpatient ServicesSurgical/Non-Surgical Inpatient AdmissionsAcute RehabSkilled Nursing Facility

Inpatient HospiceMaternity Admission (for notification only)

Outpatient Facility/Office Services (other than Inpatient)Infusion Therapy (except cancer chemotherapy, whole bloodand blood plasma) in outpatient facility and officePET ScansHysterectomyCataract SurgeryNasal Surgery for Submucous Resection, and Septoplasty

Transplants (except cornea) Comprehensive Outpatient Pain ManagementPrograms (including epidural injections)Obesity SurgerySleep Studies Uvulopalatopharyngoplasty (including laser-assisted)

Reconstructive Procedures and Potentially Cosmetic ProceduresAbdominoplastyAugmentation MammoplastyBlepharoplastyChemical PeelsDermabrasionExcision of Redundant Skin Keloid RemovalLipectomy/LiposuctionOrthognathic Surgery Procedures

MastopexyOtoplastyPanniculectomyReduction MammoplastyRemoval or Reinsertion of Breast ImplantsRhinoplastySurgery for Varicose Veins Scar RevisionSubcutaneous Mastectomy for Gynecomastia

All Home Care Services (including Infusion Therapy in the home)Birthing Center (for notification only)Elective (non-emergency) Ambulance TransportOutpatient Private Duty NursingProsthetics and Orthotics – Purchase items over $100, including repairs and replacements, and ALL rentalsDurable Medical Equipment – Purchase items over $100, including repairs and replacements, and ALL rentals(except oxygen, diabetic supplies, and unit dose medication for nebulizer).Mental Health/Serious Mental Illness/Substance AbuseMental Health and Serious Mental Illness Treatment (inpatient/outpatient/partial hospitalization)Substance Abuse Treatment (inpatient/outpatient/partial hospitalization)Biotech/Specialty Injectable Drugs

In addition to the precertification requirements listed above, the member should contact AmeriHealth and provideprenotification for certain categories of treatment so that a member will know prior to receiving treatment whether itis a covered service. Those categories of treatment (in any setting) include:

� Any surgical procedure that may be considered potentially cosmetic; and� Any procedure, treatment, drug, or device that represents “new or emerging technology;” and � Services that might be considered experimental/investigational.

A member’s provider should be able to assist the member in determining whether a proposed treatment falls into oneof these three categories. Members are encouraged to have their provider place the call for them.

PENALTIES FOR LACK OF PRECERTIFICATION:PPO In-Network and HMO/POS Referred Care: It is thenetwork provider’s responsibility to obtain prior approval forthe services listed. Members are held harmless fromfinancial penalties if the network provider does not obtainprior approval.

PPO Out-of-Network/POS Self-Referred Care: It is themember’s responsibility to initiate precertification for theservices listed. The member will be subject to 20%reduction in benefits if prior approval is not obtained for theinpatient/outpatient treatment services listed above.

THIS PRECERTIFICATION LIST IS SUBJECT TOCHANGE ANNUALLY.



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Biotech/Specialty Injectables Information for the AmeriHealth Flex Programs*

For AmeriHealth Flex Programs members, all injectables shown on the enclosed Biotech/Specialty Injectableslist require precertification. Additionally, certain Biotech/Specialty injectables require medical necessity review.Please reference the Biotech/Specialty Injectables list to determine which injectables require medical necessityreview in addition to precertification.

Procedures for Ordering and Billing Biotech/Specialty Injectables for AmeriHealth Flex Programsmembers:

� All injectables shown on the enclosed Biotech/Specialty Injectables list must be precertified throughthe Direct Ship Injectable Unit of Pharmacy Services at (888) 671-5280, option 4.

� Contact the Direct Ship Injectable Unit of Pharmacy Services at (888) 671-5280, option 4 to initiate arequest for precertification and to order Biotech/Specialty Injectables. NOTE: You will be asked tocomplete the enclosed AmeriHealth Flex Programs Injectable Order Form to precertify and orderBiotech/Specialty injectables shown on the enclosed list.

� The Direct Ship Injectable Unit of Pharmacy Services will facilitate shipping of the Biotech/Specialtyinjectable to your office for administration, or to the member’s home for self-administration.

� Do not collect a copayment for Biotech/Specialty injectables ordered through the Direct Ship InjectableUnit. The injectable vendor will bill the members for their Biotech/Specialty injectable copayment.

� Failure to precertify any of the Biotech/Specialty injectables on the enclosed list will result in a claimsdenial. Claims denied for failure to precertify are not billable to the member.

� Biotech/Specialty injectables provided in the physician’s office from a physician’s supply are subject to theBiotech/Specialty copayment described in the member’s benefits. You must notify the Direct Ship InjectableUnit of Pharmacy Services prior to the administration of any Biotech/Specialty injectable.

� Physicians must collect the Biotech/Specialty copayment when providing any of the Biotech/Specialtyinjectables from their own supply.

Standard office-based injectables not shown on the Biotech/Specialty Injectables list should not be orderedthrough Pharmacy Services. You may continue to bill standard injections, such as antibiotics and steroids, throughthe patient’s medical plan (HMO, POS, or PPO).

If you have any questions concerning ordering injectables for AmeriHealth Flex Programs members, please call theDirect Ship Unit of Pharmacy Services at (888) 671-5280, option 4.



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Biotech/Specialty Injectables List (list subject to change)Effective April 1, 2004*

Injectable Product Medical Necessity Review RequiredMULTIPLE SCLEROSIS AGENTS/INTERFERON BETA AGENTS

AvonexCopaxoneBetaseron

RebifBOTULINUM TOXIN AGENTS

Botox YesMyobloc Yes

MIGRAINE AGENTSImitrex Injection

RHEUMATOID ARTHRITIS AGENTS/TNF INHIBITORSEnbrel YesKineret YesHumira Yes

HEPATITIS/INTERFERON ALPHA AGENTSIntron A

Peg IntronRebetronPegasys

Roferon-AActimmune

AlferoneANTICOAGULANT/LOW MOLECULAR WEIGHT HEPARIN AGENTS

LovenoxFragminArixtra

InnohepOrgaran

ENDOCRINE/METABOLIC AGENTSLupronZoladexTrelstar

SandostatinHYALURONATE AGENTS

HyalganSynviscSupartz

GROWTH HORMONESNeutropin Yes

Neutropin AQ YesHumatrope Yes

Saizen YesSerostim YesProtropin Yes

Genotropin YesHEMATOPOIETIC AGENTS

EpogenProcrit

NeupogenAranespNeulastaLeukine

RESPIRATORY AGENTSXolair Yes

Synagis YesMISCELLANEOUS AGENTS

Amevive YesFuzeonForteo Yes

SomavertThyrogen



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AMERIHEALTH FLEX PROGRAMSINJECTABLE REQUEST FORM

For AmeriHealth PPO and AmeriHealth HMO and POS members enrolled in anAmeriHealth Flex Programs Option

Fax to: (215) 761- 9165MUST BE USED to request an injectable listed on Biotech/Specialty Injectables List for

AmeriHealth Flex Programs Patient InformationToday’s Date: _________________ Date Needed: ________________

Member Name: _______________________________________________________________

Address: ___________________________________ Carrier: _____________________

City: __________________ State: _____ Zip: _______ Day Phone: __________________

Member ID #: ________________________________ Evening Phone: ______________

Date of Birth: ______/_______/______ Male: � Female: �Deliver Product to: Physician’s office � Member’s Home: �

Physician InformationPhysician’s Name (please print): _________________________________________________ Office

Contact: ______________________ Office Contact Phone#: ___________________

Address: ____________________________________________________________________

City: ________________________________________ State: _______ Zip: _________

Office Phone #: _________________________ Office Fax #: ________________________

Injectable Request/Statement of Medical Necessity

Injectable Drug Requested: _____________________________________________________

Diagnosis: ____________________________________________ ICD 9 Code: ____________

Comments or Pertinent Medical History: ____________________________________________

____________________________________________________________________________

____________________________________________________________________________

Prescribed Injectable DrugRx Drug Name: _________________________ Strength: ___________ Date: _______

Sig: _____________________________________________________________________

Dispense Quantity: ______________________ Refills*: ____________

Phys. License #: ________________________ DEA#: __________________________

Physician Signature: ______________________ __________________________Substitution Permissible: � Dispense as Written: �

For Internal Use OnlyINFO Doc #: Date Rec: Cov: Y N Med Rx MSIQ: MHS Budget Code: Medco Paid Grp:*A new form is not needed for each refill. Refills will be coordinated by the Injectable distributor.

par tners health update€¦ · upda te 3 march 2004 billing reminders: 10-digit hmo provider id...

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