Provider Newsletterhttps://providers.amerigroup.com/��

June 2019GA-NL-0181-19

Table of ContentsHow to contact IngenioRx Specialty Pharmacy beginning May 1, 2019

Page 2

2019 Utilization Management Affirmative Statement concerning utilization management decisions

Page 2

Members’ Rights and Responsibilities Statement Page 2

Why do patients stop taking their prescribed medications and what can you do to help them?

Page 3

Complex Case Management program Page 3

Intervention for blood sugar control in pregnant women with diabetes

Page 4

Clinical Criteria updates Page 5Update: evaluation and management with Modifier 25 Page 5

Important information about utilization management Page 5

OB Spotlight: Southern Crescent Women’s Healthcare Page 6

Reimbursement Policy:Professional Anesthesia Services Page 7

June 2019

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2019 Utilization Management Affirmative Statement concerning utilization management decisions

All associates who make utilization management (UM) decisions are required to adhere to the following principles:

� UM decision making is based only on appropriateness of care and service and existence of coverage.

� We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support or tend to support denials of benefits.

� Financial incentives for UM decision makers do not encourage decisions that result in underutilization or create barriers to care and service.

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Members’ Rights and Responsibilities Statement

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment, participating practitioners and members in our system, Amerigroup Community Care has adopted a Members’ Rights and Responsibilities Statement.

To access the statement, go to https://providers.amerigroup.com/GA > Health & Wellness > Quality > Member Rights & Responsibilities. If you need a physical copy of the statement, call Provider Services at 1-800-454-3730.GA-NL-0171-19

How to contact IngenioRx Specialty Pharmacy beginning May 1, 2019

As of May 1, 2019, IngenioRx is the pharmacy benefit manager (PBM) for prescription drugs, mail-order pharmacy* and specialty pharmacy for Amerigroup Community Care members. Because Amerigroup and IngenioRx are both Anthem, Inc. companies, your patients gain fast, easy access to their health and prescription benefits in one place.

Contacting IngenioRx Specialty PharmacyIf you need to contact IngenioRx Specialty Pharmacy regarding a Medicaid member, they can be reached in the following ways:

� Phone: 1-833-262-1726 (24 hours/7 days a week) � Fax: 1-833-263-2871

If you have questions about this change, contact your local Provider Relations representative or call Provider Services at 1-800-454-3730. *not available in all marketsGA-NL-0178-19

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Why do patients stop taking their prescribed medications and what can you do to help them?

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50 percent of patients with chronic illness stop taking their medications within one year of being prescribed.1 What can be done differently?

The missed opportunity may be that you’re only seeing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

1 Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm.

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Complex Case Management program

Managing illness can be a daunting task for our members. It is not always easy to understand test results or know how to obtain essential resources for treatment or who to contact with questions and concerns.

Amerigroup Community Care is available to offer assistance in these difficult moments with our Complex Care Management program. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals who support members, families, primary care physicians and caregivers. The Complex Care Management process utilizes the experience and expertise of the Care Coordination team to educate and empower our members by increasing self-management skills. The Complex Care Management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the Customer Service number located on their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about health care decisions and goals.

You can contact us by phone at 678-587-4840. Case Management business hours are Monday-Friday from 8:30 a.m.-5 p.m. Eastern time.GA-NL-0171-19

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Intervention for blood sugar control in pregnant women with diabetes

In an effort to help your patients maintain healthy blood sugar levels throughout pregnancy, reduce the probability that babies will be born weighing greater than 4,500 grams and, thereby, reduce the potential for Cesarean section, Amerigroup Community Care offers the Diabetes in Pregnancy program to support you and your patients. Eligible Amerigroup members in need of additional support may be enrolled in case management and referred to a registered dietitian/nutritionist or certified diabetes educator.

The program includes providing meal planning assistance, physical activity interventions, weight gain interventions and monitoring blood sugar patterns. Pregnant members with diabetes are identified as early as possible and are targeted for outreach to engage in case management.

Diabetes in pregnancyThe common types of diabetes seen during pregnancy are type 1, type 2 and gestational diabetes, which is defined as diabetes first diagnosed in the second or third trimester of pregnancy that is clearly neither pre-existing type 1 or type 2 diabetes. According to the Centers for Disease Control and Prevention, pre-existing diabetes occurs in 1-2 percent of all pregnancies and gestational diabetes in 6-9 percent of pregnancies.1

While pregnancy complicated with diabetes is a low percentage of all pregnancies, the risk of Cesarean sections is much higher in this population than for women with uncomplicated pregnancies. Sixty-four percent of women with pre-existing diabetes and 46 percent of women with gestational diabetes will have a Cesarean section compared to 32 percent of women who do not have diabetes during pregnancy.2

Whether diagnosed with type 1 or type 2 diabetes or diagnosed with gestational diabetes, blood sugar control is essential for the health and well-being of mother and infant. All types of diabetes put the baby at risk for macrosomia, making a Cesarean section delivery more likely.3 Research indicates that early lifestyle interventions, such as meal planning and physical activity, can help women reach healthy blood sugar targets more quickly and help them stay in target longer, thus reducing the risk of macrosomia in the infant.4

According to the American College of Obstetricians and Gynecologists, Cesarean sections should be limited to babies of at least 4,500 grams in mothers with diabetes.

For more informationIf you have a patient who would benefit from speaking with an Amerigroup registered dietitian/nutritionist, certified diabetes educator or an obstetric case manager, please call Provider Services at 1-800-454-3730 and ask for a case management referral for the member. If you would like more information on the Diabetes in Pregnancy program, please contact Provider Services at the number above.1 Retrieved from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/diabetes-during-pregnancy.htm.2 Agency for Healthcare Research and Quality Statistical Brief #102. Retrieved from: https://www.hcup-us.ahrq.gov/reports/

statbriefs/sb102.jsp.3 The New England Journal of Medicine, May 8, 2008 vol. 358 no. 19. Hyperglycemia and Adverse Pregnancy Outcomes, The HAPO

Study Cooperative Research Group. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJMoa0707943.4 Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-

analysis of individual participant data from randomized trials. BMJ 2017;358:j3119 DOI: 10.1136/bmj.j3119 (Published 19 July 2017).

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Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website.

You can request a free copy of our UM criteria by calling Provider Services at 1-800-454-3730. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the number listed below. To access UM criteria online.

We are staffed with clinical professionals who coordinate our members’ care. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests via: https://www.mmis.georgia.gov or https://www.availity.com.

Additionally, providers should use our provider website and the Precertification Lookup Tool to identify those services requiring prior authorization.

Have questions about utilization decisions or the UM process?Call our Clinical team at 1-800-454-3730 Monday-Friday from 8:30 a.m.-5 p.m. Eastern time.GA-NL-0171-19

Clinical Criteria updates

On August 17, 2018, October 9, 2018, and November 16, 2018, the pharmacy and therapeutic (P&T) committee approved Clinical Criteria applicable to the medical drug benefit for Amerigroup Community Care. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the Amerigroup provider website, and the effective dates are reflected in the Clinical Criteria updates notification. Visit the Clinical Criteria website to search for specific policies.

Email for questions or additional information.GA-NL-0159-19

Update: evaluation and management with Modifier 25

Amerigroup Community Care has identified that providers often bill a duplicate evaluation and management (E&M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure, which included an E&M service for the same or similar diagnosis. The use of Modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Amerigroup policy on use of Modifier 25.

Beginning with claims processed on or after September 1, 2019 , Amerigroup may deny the E&M service with a Modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.

If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant and separately identifiable E&M service, please submit those medical records for consideration.GAPEC-2789-19

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OB Spotlight: Southern Crescent Women’s Healthcare

For over 35 years, Southern Crescent Women’s Healthcare (SCWH) has been providing women’s health care services throughout the state of Georgia. Their vision is to offer compassionate and competent care and to foster respectful provider/patient relationships. SCWH is committed to patient safety and quality, as evidenced by being the first private practice in the State of Georgia to receive the Safety Certification in Outpatient Excellence for Women’s Health (SCOPE certification) from the American College of Obstetricians and Gynecologists (ACOG). Their dedication has shaped them into a leader in OB/GYN in their region. Over a 24-month analysis, SCWH has continuously exceeded the national and state benchmarks for overall C-section, vaginal birth after a cesarean (VBAC) and postpartum care completion rates. For these amazing outcomes, they are the focus of this month’s OB Spotlight.

“Postpartum care completion, which is defined as the percentage of members who received a postpartum visit within 21-56 days of delivery, is one of the maternity benchmarks set by the Healthcare Effectiveness Data and Information Set (HEDIS®) and developed by the National Committee for Quality Assurance. To support their large delivery volume, SCWH started using a web-based birth log, which enables them to track delivery dates and schedule postpartum appointments with ease. They have a staff member who calls patients within just a few days of delivery to schedule their postpartum appointments. During hospital rounding, providers will either encourage delivered patients to schedule their postpartum appointment at that time or will even call to schedule for them.

They have also taken the ACOG recommendations regarding the labor curve to bedside, waiting longer for spontaneous, active labor to commence. This means they never perform elective inductions before 39 weeks. For patients past 39 weeks, providers will only induce if they establish the patient has a suitable Bishop score.

SCWH has established qualifying criteria for patients who desire VBAC. If a patient meets the qualifying criteria, SCWH providers meticulously review the patient’s case to determine if trial of labor after cesarean is reasonable. Providers educate their patients as to why VBACs are not an option for everyone, and they report very low VBAC complication rates.

Throughout the entire obstetrical episode, the practice provides literature and promotes local prenatal educational opportunities for their patients. SCWH also partnered with Amerigroup Community Care and hosted their first in-house Smart Choice Breastfeeding Workshop in January 2019.

Please join us in applauding Southern Crescent Women’s Healthcare for their hard work and exceptional quality outcomes for OB!HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).GA-NL-0174-19

” Southern Crescent Women’s Healthcare is committed to

patient safety and quality, as evidenced by being the first private practice in the State of Georgia to receive the

Safety Certification in Outpatient Excellence for Women’s Health from the American College of Obstetricians and Gynecologists.

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”

Reimbursement Policy

Policy UpdateProfessional Anesthesia Services(Policy 06-019, effective 09/01/2019)

Amerigroup Community Care allows reimbursement of anesthesia services rendered by professional providers for covered members. Reimbursement is based upon:

� The reimbursement formula for the allowance and time increments in accordance with state guidelines.

� Proper use of applicable modifiers.

Providers must report anesthesia services in minutes. Anesthesia claims submitted with an indicator other than minutes may be rejected or denied. Start and stop times must be documented in the member’s medical record. Anesthesia time starts with the preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance. The reimbursement formula for anesthesia allowance is based on state guidelines.

Effective September 1, 2019, Amerigroup reimburses neuraxial epidural anesthesia services provided in conjunction with labor and delivery at a flat rate regardless of number of minutes.

Please refer to the Professional Anesthesia Services reimbursement policy for additional details at https://providers.amerigroup.com/GA > Quick Tools > Reimbursement Policies > Medicaid/Medicare.GA-NL-0149-18