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U P D A T E

W O R K I N G

T O G E T H E R

F O R

INSIDE THIS ISSUE: DECEMBER 2004

Q U A L I T Y

H E A L T H C A R E

www.amerihealth.com

ANNOUNCEMENTS • • • •

Influenza Vaccine Update New Jersey PCP Capitated Laboratory Reminder Member Empowerment in Consumer-Driven Health Care Programs Reminder to Refer to Participating Providers

PHARMACY ANNOUNCEMENTS • Select Drug Program® Formulary • Standard Drug List Available on our Website • Depression Pharmacology Treatment Guide • Important Information About Prescription Drug Coverage

FOR MEMBER’S HEALTH • Clinical Practice Guidelines and Preventive Health Guideline Update • Procedure/Diagnosis Code Release Schedule • AmeriHealth and Its Affiliates (AmeriHealth) Pricing Procedure for Unlisted or Not Otherwise Classified (NOC) Services • Supporting Our Members, Your Patients: ConnectionsSM Health Management Programs

BILLING TIPS • Distinct Procedural Service Modifier-59 Reminder • Avoid Claims Rejections • New 13-Position Member Identification Number • Billing Requirements for Outpatient Radiology and Lab Services at Participating Hospitals • AIM Precertification Requirement for Radiology Services, Effective January 1, 2005 • Billing Requirement: Use Complete Member ID Number • Important AmeriHealth Billing Information for AmeriHealth PPO, Traditional Medical/Preferred Provider Network, and Comprehensive Major Medical (CMM) Products

GET CONNECTED • “Do It All” with NaviNetSM: Simplify Drug Preauthorization • Member Eligibility Information Available Quickly and Efficiently

POLICY • Credentialing Compliance Hotline and Web Page

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ANNOUNCEMENTS

U P D A T E

Influenza Vaccine Update The Centers for Disease Control and Prevention (CDC), in coordination with its Advisory Committee for Immunization Practices (ACIP), has issued updated interim recommendations for influenza vaccination during the 2004-05 season. A complete list of recommendations, including details on priority groups, is available at www.cdc.gov/nip/flu. In accordance with the ACIP recommendations, existing flu vaccine supplies should be administered to people who are at greatest risk for serious complications from influenza. Healthy people 2 to 64 years of age are asked to postpone or skip getting a flu shot this year so that available vaccines can go to protect those at greater risk for flu complications. The CDC has

recommended the use of FluMistTM as an option for select healthy individuals, 5 to 49 years of age, who are not pregnant. Pregnant women are still to be given the flu vaccine, according to the CDC. Managed care members may receive their influenza vaccine from their Primary Care Physician (PCP) or a participating specialist. Referral requirements for HMO members receiving influenza vaccine from a specialist have been waived during this year’s flu season. Please refer to the Influenza Vaccine Update mailing recently sent to your office for more information. You can also access this information via NaviNetSM.

New Jersey PCP Capitated Laboratory Reminder New Jersey PCPs, please verify that you have selected a laboratory provider for your practice. Ensuring that your practice has selected a capitated laboratory provider will allow for the proper adjudication of claims, prevent member

balance bills, and ensure that specialists know where to refer members for laboratory studies. Please contact your Network Coordinator to select a capitated laboratory or for further details.

Member Empowerment in Consumer-Driven Health Care Programs To meet changing health care industry trends, AmeriHealth provides several resources for members that are designed to meet the demands of consumer-driven health care.These tools encourage members to take an active role in their health care and to make informed decisions about their treatment options by: • Directly managing their health account and sharing in the decision making and costs for health care services. • Accessing information to help them learn more about their health conditions and the treatment options available. • Taking responsibility for their health care and sharing in controlling costs.

www.amerihealthexpress.com Through our convenient and secure website, www.amerihealthexpress.com, we support members with information that helps them make informed health care decisions and manage their Health Accounts:

December 2004

• Healthwise® Knowledgebase: Information on a variety of health related topics, including how to better manage chronic conditions such as diabetes or everyday health concerns like how to treat a mild bee sting, or what to expect from a medical test.

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• Provider Finder: A tool to locate network doctors and hospitals, including information on office hours, languages spoken, and more. • Online Account Management: Check Health Accounts balances, view health plan claims status, print statements, review transaction history, and more.

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Reminder to Refer to Participating Providers

• Nature of services to be provided. • AmeriHealth will neither pay nor be liable for the services. • Member will be financially liable for the services. In the event the participating provider does not inform the member of the above in writing, the member must be held harmless.

event that the covering physician does not participate with AmeriHealth, the participating physician should obtain prior written approval from AmeriHealth for the intended coverage arrangement. The participating provider should also ensure that the covering physician: • Will not seek compensation from AmeriHealth for services if the participating physician receives compensation from AmeriHealth. • Will not bill members or beneficiaries for covered services under any circumstances, except for applicable copayments as required under the applicable Benefits Program. • Will obtain preapproval from AmeriHealth and/or referrals, except in emergencies, where required or permitted under the applicable Benefits Program, Benefits Program Arrangements, or as otherwise required by law.

Subcontracting When referring POS or PPO members, please note that a referral to an out-of-network provider will result in higher out-of-pocket costs to your patients.

Coverage

Please consult our online Provider Directories at www.amerihealth.com/providers. For any other questions, please call Provider Services.

December 2004

In the event of a participating provider’s illness, vacation, or other absence from his or her practice, participating providers shall arrange for coverage pursuant to the terms of their Provider Agreement. Please note that all covering physicians should participate with AmeriHealth. In the

A participating provider must not subcontract for the performance of covered services without prior written consent of AmeriHealth. Upon approval, each subcontractor shall be required to be a participating provider with AmeriHealth.

U P D A T E

Except in emergent situations, all participating providers must refer HMO members or beneficiaries to participating providers for covered services. This includes services provided in your office by another specialty physician. If a participating provider cannot provide care, and a referral to a non-participating provider is contemplated, such a referral requires preapproval. In the event that a provider refers a member to a non-participating provider without preapproval, the provider must inform the member in writing of the following:

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PHARMACY ANNOUNCEMENTS

U P D A T E

Select Drug Program® Formulary The Select Drug Program® Formulary was developed to offer our members high-quality pharmacy benefits at an affordable price. The program provides savings for members through the use of the medications included in the formulary. When you prescribe a medication listed on the formulary, members can receive the drug for a lower copayment. If you prescribe, or if a member wishes to receive, a drug that is not on the formulary, the member’s out-of-pocket cost is greater. The amount of increase depends on the member’s specific pharmacy benefit plan. When developing the Select Drug Program Formulary, the Pharmacy and Therapeutics Committee chose to include at least two agents to treat each covered disease state. The entire formulary is reviewed annually to consider the addition of new drugs or to remove drugs when better alternatives become available. You can prescribe any covered medication, regardless of whether the drug is on the formulary or not. The formulary is a list of preferred medications intended to help members receive pharmaceutical coverage at a lower out-of-pocket expense. Medications on this list may be subject to the member’s contract exclusion and other Pharmacy edits. Members enrolled in the Select Drug Program have “SELRX” imprinted on the front of their ID cards. Before prescribing a medication to these members, you should work with patients to determine if the drug is included on the formulary. If a patient is currently taking a drug that does not appear on the formulary, you may be able to change the prescription to a similar drug that is on the formulary.

Additional Select Drug Program details include:

December 2004

• Members in the Select Drug Program pay a fixed copayment for up to a 30-day supply of drugs listed on the formulary. • Covered drugs not listed on the formulary will be available at higher copayment levels at participating pharmacies. • Since non-formulary prescriptions may result in higher copayments for members, you may want to review the Select Drug Program Formulary to aid your prescribing.

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including a Select Drug Program Formulary Guide for reference when visiting your office. To obtain a copy of the Select Drug Program Formulary, contact the Provider Supply Line or visit our website, www.amerihealth.com.

Requests for Formulary Copayment Exceptions (specific to Select Drug Program members only) Providers may request formulary coverage of a non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The practitioner should complete the Non-formulary Exception Request Form providing detail to support use of the non-formulary medication and fax the request to (215) 241-3073 or (888) 671-5285. You may obtain a copy of the Non-formulary Exception Request Form on our website, www.amerihealth.com, or by calling (888) 671-5280. If the non-formulary request is approved, the drug will be processed at the appropriate formulary benefit copayment. If the request is denied, the member and practitioner will receive a denial letter that explains the appeal process. The member may still receive benefits for the covered non-formulary drug at the non-formulary copayment or non-formulary coinsurance.

Requests for Inclusion of Medication on the Formulary You may petition for the inclusion of a medication or dosage in the formulary. To do so, make your request in writing to: Pharmacy Services AmeriHealth 1901 Market Street Philadelphia, PA 19103 If you have any questions concerning prescription drug benefits, please call Provider Services.

To help members understand this program, Select Drug Program members should receive educational materials,

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Standard Drug List Available on our Website In order to provide up-to-date information about available Pharmacy Benefits, we have added the Standard Drug Program List of Preferred Drugs to the Pharmacy section of our website at www.amerihealth.com/providers. This is in addition to the Select Drug Program® Formulary and other useful Pharmacy Benefit Information.

The Depression Pharmacology Treatment Guide, developed in collaboration with our Pharmacy Department and Magellan Behavioral Health, offers information on the use of pharmaceuticals in treating members with depression. This guide is available by calling the Provider Supply Line or visiting our website at www.amerihealth.com.

Important Information About Prescription Drug Coverage

Anti-Infectives • Vfend® powder for oral suspension (voriconazole)

Autonomic & CNS Drugs, Neurology & Psych • Avinza® (morphine sulfate) - Avinza® is included in the Schedule II Oral Tablet/Capsule/Lozenge Quantity Level Limits Policy. Prior Authorization is required for quantities greater than 60 capsules per prescription. To obtain prior authorization, fax a prior authorization form to the Pharmacy Services Department at (888) 671-5285. Forms may be obtained at www.amerihealth.com or by calling (888) 671-5280 option 1. Providers registered with NaviNetSM may use this system to submit drug prior authorization requests.

Cardiovascular, Hypertension, & Lipids • Avapro® (irbesartan) • Avalide® (irbesartan/HCTZ)

Endocrinology/Diabetes • Sensipar® (cinacalcet) • Avandamet® (rosiglitazone/metformin) • Novo Insulin Products including: - Novolin N Inj U-100 - Novolin N Inj Innolet - Novolin N Inj Penfill - Novolin R Inj U-100 - Novolin R Inj Innolet - Novolin R Inj Penfill - Novolin Inj 70/30 - Novolin 70/ Inj 30 Innolet - Novolin 70/ Inj 30 Penfil - Novolog Inj 100/Ml - Novolog Inj Flexpen - Novolog Inj Penfill - Novolog Mix® Inj Syringe - Novolog Mix® Inj Cartridge - Novolog Mix® Sus 70/30

Musculoskeletal & Rheumatology • Fosamax® solution (alendronate)

Obstetrics & Gynecology • Cenestin® (synthetic conjugated estrogens, A) • Cyclessa® (desogestrel/ethinyl estradiol) • NuvaRing® (etonorgestrel/ethinyl estradiol) • Seasonale® (levonorgestrel/ethinyl estradiol) • Tri-Norinyl® (norethindrone/ethinyl estradiol) • Vivelle-Dot® (estradiol transdermal) • Yasmin® (drospirenone/ethinyl estradiol)

www.amerihealth.com

December 2004

The following brand drugs have been added to the Select Drug Program® Formulary, effective immediately. These brand drugs are now available to members at the brand formulary copayment. These brand drug additions are listed under their respective formulary chapters.

U P D A T E

Depression Pharmacology Treatment Guide

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FOR MEMBER’S HEALTH Clinical Practice Guidelines and Preventive Health Guideline Update

U P D A T E

AmeriHealth is pleased to make available the enclosed copies of the 2004 Clinical Practice Guidelines grid and the 2004 Preventive Health Guideline.

Clinical Practice Guidelines The Clinical Practice Guidelines grid includes all Plan Clinical Practice Guidelines with reference information and source URLs (when available) on the following: Asthma; CAD; CHF; COPD; Diabetes; Hyperlipidemia; Hypertension; ESRD; Preventive Health; Tobacco Cessation; Major Depression; Assessing and Managing the Suicidal Patient; Substance Abuse; and Schizophrenia. Clinical Practice Guidelines are a generally accepted minimum standard of care in the medical profession. Adherence to these guidelines may lead to improved patient outcomes. Individual clinical decisions should be tailored to specific patient medical and psychosocial needs. As national guideline recommendations evolve, please update your practice accordingly.

The guidelines are not a statement of benefits. Benefits may vary based on state requirements, product line (HMO, PPO, etc.), or employer group. Individual member coverage will need to be verified with the Plan. Please contact Provider Services for more information on specific benefit coverage. You may also access the Clinical Practice Guidelines on our website at www.amerihealth.com/providers. In addition, you may visit our website for a copy of Clinical Insights. These documents are summaries of the key points in the ConnectionsSM Health Management Programs. If you do not have internet access, please call the Provider Supply Line to request a copy of any of our guidelines or Clinical Insights. If you have any questions or concerns regarding member coverage or benefits, please contact Provider Services.

Annually, AmeriHealth performs an internet literature search of several nationally recognized sources for updates and changes to the plan guidelines. Changes are reviewed by internal and external consultants and are incorporated as appropriate into the guidelines.

December 2004

SUPPORTING OUR MEMBERS, YOUR PATIENTS: CONNECTIONSSM HEALTH MANAGEMENT PROGRAMS

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HELPING YOU AND YOUR PATIENTS MANAGE FIVE CHRONIC CONDITIONS (Asthma, CAD, CHF, COPD, and Diabetes) SM CONTACT THE CONNECTIONS PROGRAMS PROVIDER SUPPORT LINE AT (866) 866-4694 TO: • Refer a member for Health Coaching. • Ask questions or provide feedback. TM the SMART Registry. • Request information regarding SM • Request Connections posters for your office, referral pads, or copies of the Connections Programs Clinical Guidelines and Clinical Insights. • Request patient information for the purposes of treatment or care coordination for your patient.

PROVIDING RESOURCES FOR YOU AND YOUR PATIENTS WITH END-STAGE RENAL DISEASE SM

CONTACT THE CONNECTIONS KIDNEY PROGRAM AT (866) 303-4CKP [4257] TO: •Refer a member on chronic dialysis to a Health Service Coordinator. •Ask questions or provide feedback. •Request individual member information.

A ConnectionsSM Provider Service Specialist will return your call within two business days.

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BILLING TIPS Procedure/Diagnosis Code Release Schedule

• CPT procedure codes: Biannual release of codes with effective dates of January 1 and July 1. • HCPCS procedure codes: Quarterly release of codes with effective dates of January 1, April 1, July 1, and October 1.

As previously communicated, AmeriHealth will no longer allow the 90-day grace period on deleted procedure and diagnosis codes beginning with the ICD-9 procedure and diagnosis code update (October 2004) and the CPT and HCPCS procedure code update ( January 2005). Therefore, the provider must submit only the CPT, HCPCS, and/or ICD-9 codes that are valid at the time that a service is provided. * Current Procedural Terminology (CPT) is copyright 2003 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

AmeriHealth and Its Affiliates (AmeriHealth) Pricing Procedure for Unlisted or Not Otherwise Classified (NOC) Services AmeriHealth is pleased to announce that its pricing and processing procedure, as set forth below, for unlisted or not otherwise classified (NOC) covered services is expected to be fully implemented in the first quarter of 2005 for all products covered under your provider agreement. All unlisted/NOC codes must be submitted with the appropriate narrative description of the actual services rendered on the CMS 1500 claim form in order to be processed. For claims that are electronically submitted, please refer to your HIPAA 837 Companion Guide. (You can connect to the Guide at our website, www.amerihealth.com/edi.)

For paper submitted claims, additional information regarding where the narrative description should be submitted within block 24D, directly under the NOC/ unlisted procedure code on the CMS 1500 claim form. If a description is not provided, the entire claim will be rejected with a message to resubmit with a narrative description. The following describes the standard process followed by AmeriHealth for processing and pricing unlisted/NOC services: 1. AmeriHealth maintains a database of historical pricing

decisions for similar services previously reviewed and priced by AmeriHealth. If available, an appropriate fee in this database may be used to price the current claim.

2. If the database does not include pricing of the current claim,

U P D A T E

National entities, including AMA, CMS, and the Department of Health and Human Services release scheduled updates to CPT, HCPCS, and ICD-9 procedure/diagnosis codes, respectively. AmeriHealth monitors those schedules and reacts according to the following timeline (Note: timeline reflects schedule of entity and therefore may be subject to change):

• ICD-9 procedure/diagnosis codes: Biannual release of codes with effective dates of April 1 and October 1 (Note: Biannual release becomes effective beginning with 2005 code updates; release was previously on an annual basis).

then the claim is reviewed by AmeriHealth for a pricing decision. Amerihealth may request that the provider submit additional information to facilitate pricing the claim. The additional information requested may include (but is not limited to) an operative report, a letter of medical necessity, an office note, and/or an actual manufacturer’s invoice. Providers should only submit additional information if specifically requested to do so by AmeriHealth. When recommended for payment and processing, claims are priced using our standard pricing methodology, which is designed to take into account new procedures and processed in accordance with applicable claim payment policies and benefit contract exclusions and limitations. 3. Providers who disagree with a specific unlisted/NOC

service pricing determination should follow the normal appeals process described in the Provider Manual. Providers are reminded to always use the most appropriate codes when submitting claims. Providers who use NOC codes inappropriately may be subject to further investigation. More information regarding the full implementation of this procedure will be forthcoming. If you have any questions, please contact Provider Services or your Network Coordinator.

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December 2004

The Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code Sets Rules will require providers to use only the CPT*, HCPCS, and/or ICD-9 codes that are valid at the time that a service is provided.

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BILLING TIPS Distinct Procedural Service Modifier-59 Reminder

U P D A T E

In December 2003, AmeriHealth and its affiliates (AmeriHealth) revised the reimbursement methodologies regarding Distinct Procedural Service Modifier-59. When appropriate, this modifier should be appended only to those services designated by the American Medical Association (AMA) Current Procedural Terminology (CPT) as “separate procedures.” Services defined by CPT as “separate procedures” are commonly performed as an integral component of another service. Under most circumstances, they should not be reported in addition to the code for the total procedure unless carried out independently or considered to be unrelated and/or distinct from the other procedure(s) performed. Modifier-59 is appended to “separate procedures” to describe unusual circumstances for which the provider may need to indicate that the procedure is not considered a component of another procedure but is actually an independent and unrelated service. Modifier-59 is used to identify procedures that are not normally reported together, but are appropriate under the circumstances. When the “separate procedure” performed meets medical necessity and is a valid and eligible procedure code, the following circumstances are appropriate in appending modifier-59: • Services are performed on the same date but during a different session or patient encounter OR • Services are performed at the same session but at a different anatomic site or organ system OR • Services are performed on different lesions, through a separate incision/excision or for a separate injury (or area of injuries in extensive injuries) AND • Services performed are procedures not ordinarily encountered or performed on the same day by the same physician AND

• There is no other modifier that describes the situation more accurately. It is not appropriate, however, to report modifier-59 in the following circumstances, because either a more appropriate modifier exists to describe the service or the concept of using modifier-59 as described is not applicable to the reported service: • Appending modifier-59 to E/M codes. • Using modifier-59 as a replacement for modifiers 24, 25, 78, or 79. • Using modifier-59 when another modifier best describes the distinct service. • Reporting modifier-59 with modifier-51 on the same CPT code. Billing providers should verify that the medical record clearly supports the appropriate use of modifier-59 and be able to provide documentation upon request. Claims submitted with modifier-59 are subject to postpayment clinical review and potential retractions for inappropriate use.

Claim Payment Policy Note This policy, in whole or in part, is part of the class action settlement with providers. Please note that providers who opted out of the class action settlement may not be entitled to certain claim payment policy changes. Therefore, any payments made pursuant to such policy changes to providers who opted out of the class action settlement are subject to retroactive adjustments.

Avoid Claims Rejections

December 2004

The Performing Provider ID Number Must Be Recorded on All Claims

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This is a required data element in conjunction with HIPAA compliance and other requirements. HMO, POS, and PPO claims submitted without the identification number of the physician or other professional provider performing the procedure or service are being rejected and returned as non-clean claims and must be resubmitted with the necessary information.

10-Digit HMO Provider ID Number Required

referrals, and related correspondence since January 1, 2003. HMO and POS claims submitted without the 10-digit HMO provider ID number are being rejected as non-clean claims. Both your Group Provider ID Number and the Performing Provider ID Number (PIN#) need to reflect the 10-digit HMO Provider ID numbers. This requirement applies to paper and electronic claims submissions. Please note the following: The provider ID numbers that you currently use for AmeriHealth PPO services are not affected and continue to be valid for AmeriHealth PPO claims and related correspondence.

The 10-Digit HMO Provider ID Number has been required on all HMO and POS claims submissions, encounters,

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New 13-Position Member Identification Number which defines a member of the family unit. Beginning in spring 2005, this new Member Identification Number is due to become effective and members will be issued new ID cards. As we finalize the details in the upcoming months, please look for more information in future editions of monthly Partners in Health Update . Please call Provider Services or your Network Coordinator with questions.

New Member Identification Number (Effective Spring ‘05) 3-position alpha/numeric prefix + 8-position ID number + 2-position suffix = 13 positions

Billing Requirements for Outpatient Radiology and Lab Services at Participating Hospitals Please review these billing requirements for providers who perform diagnostic radiology or laboratory services in the outpatient setting of a participating hospital. Billing requirements for box 32 of the CMS 1500 form include the Medicare provider number of the hospital where the services are rendered. The name and address of the hospital continues to be required in box 32. Below is a listing of the required electronic formats:

Please submit the facility name, address, city/state/zip code, and the Medicare provider number (10 digits, zero filled) within the lines of box 32 (left justified). If box 32 does not contain the correct data, ID number, or city/state/zip code, the claim will reject with the message: “Data is required in box 32 to process the claim.” Please contact Provider Services or your Network Coordinator if you or your vendor have any questions about populating box 32.

NSF

HIPAA 837P

Description

Record

ID Facility Address Facility Address 2 Facility City Facility State Facility ZIP

EA1 EA1 EA1 EA1 EA1 EA1

Field

U P D A T E

As you may know, various states have enacted laws to limit the use of a member’s Social Security Number (SSN) on member communications. As a result of this legislation, and to better protect member identity and privacy, AmeriHealth and its affiliates have chosen to create a non SSN-based identifier for members to be used on external communications to the member, including member identification cards. The new Member Identification Number will consist of a 3-position alpha/numeric prefix, an 8-position ID number, along with a 2-position suffix

Loop ID Segment

4 6 7 8 9 10

2310D 2310D 2310D 2310D 2310D 2310D

REF02 NM103 N302 N401 N402 N403

As reported in the July 2004 Partners in Health Update, AmeriHealth New Jersey has contracted with American Imaging Management, Inc. (AIM) to implement the Radiology Quality Initiative program.* Beginning January 1, 2005, the imaging services noted below will be subject to precertification under AmeriHealth benefit programs; AmeriHealth network physicians are now required to contact AIM before providing any of these services: CT Scan, Nuclear Cardiac Studies, MRI, MRA, and PET Scans. AmeriHealth PPO, AmeriHealth Point-of-Service, AmeriHealth POS Plus, and AmeriHealth Traditional Medical members using an out-of-network provider for a CT Scan, MRI, MRA, Nuclear Cardiac Study, or PET scan

after January 1, 2005, will be responsible for contacting AIM before scheduling the procedure. Failure to notify AIM in advance of receiving these services from an out-of-network provider will result in a reduction in benefits. Please note that this program does not impact the current preauthorization requirements under the AmeriHealth PPO program for out-of-network radiological procedures (i.e., CT Scan or MRI services). For questions regarding the program, please contact the AIM Customer Service Department at (800) 252-2021. For claims related questions, please contact AmeriHealth New Jersey Provider Services at (800) 821-9412. * Certain employer groups do not participate in this program. Please contact Member Services for more information about your personal benefit plan.

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December 2004

AIM Precertification Requirement for Radiology Services, Effective January 1, 2005

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BILLING TIPS Billing Requirement: Use Complete Member ID Number

U P D A T E

To facilitate claims processing, please include the complete member identification number as it appears on the member’s ID card. For AmeriHealth PPO, AmeriHealth Traditional Medical and Comprehensive Major Medical (CMM) members, please include the 3-position alpha/numeric claim

router located at the beginning of the member’s ID number when submitting all claims. Please note, the lab indicator (for example, “A”, “H”, “L”, “M”, “N”, “T”, or “Q”) located on the front of HMO and POS ID cards should not be included in the member’s ID number.

Important AmeriHealth Billing Information for AmeriHealth PPO, Traditional Medical/Preferred Provider Network, and Comprehensive Major Medical (CMM) Products As noted in August 2004 Partners in Health Monthly Update, AmeriHealth PPO, AmeriHealth Traditional Medical/Preferred Provider Network, and AmeriHealth Comprehensive Major Medical (CMM) products were transferred to our managed care information system, PowerMHS™, effective November 1, 2004. PowerMHS™ has been enhanced to include updated National Association of Insurance Commissioners (NAIC) codes for use effective November 1, 2004. We have previously transitioned AmeriHealth HMO and Pointof-Service products to this system. We encourage you to prepare for this change as outlined below.

Electronic Billers: NAIC Code Requirements Effective for Claims Submitted On or After November 1, 2004, Regardless of Dates of Service

Please share this information with your software and clearinghouse vendors to ensure there is no disruption in your claims payment. If you currently submit claims via a billing

X12 837P format (version 4010A1) require the NAIC code of 54704 in ISA-08 in order to be routed correctly. Please use NAIC code 54704 in ISA-08 for AmeriHealth PPO, AmeriHealth Traditional Medical/Preferred Provider Network, and AmeriHealth CMM claims effective November 1, 2004, regardless of dates of service. This same code is presently used when electronically submitting AmeriHealth HMO and Point-of-Service claims. Continue to include the GS-03 NAIC code when submitting all claims to identify the line of business. Questions regarding this electronic billing change should be directed to the AmeriHealth eBusiness Help Desk at (215) 241-2305, or via email to [email protected].

Paper Claims Submission Paper claims for AmeriHealth PPO, AmeriHealth Traditional Medical/Preferred Provider Network, and AmeriHealth CMM should continue to be submitted to:

software vendor or a clearinghouse (Web MD / Envoy, Misys, etc.), please consult with them to determine if the following requires changes to their software, changes to your coding procedures, or no change at all.

AmeriHealth Processing Center P.O. Box 41574 Philadelphia, PA 19101-1574

Effective November 1, 2004, the electronic submission of AmeriHealth PPO, Traditional Medical/Preferred Provider Network, and CMM claims in HIPAA compliant ANSI

If you have any questions regarding this new billing information, please contact Provider Services or your Network Coordinator.

NAIC Codes for Electronic Billers (ANSI X12 837P-4010A1)

December 2004

Pr

10

Product

AmeriHealth NJ Point-of-Service*/PPO/ Traditional Medical/Preferred Provider Network AmeriHealth DE Point-of-Service*/ PPO / CMM AmeriHealth NJ/DE HMO* AmeriHealth Administrators*

ISA-08

GS-03

NAIC Code

NAIC Code 60061

54704

*No change has been made to the billing requirements

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93688 95044 54763

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GET CONNECTED “DO IT ALL” WITH NAVINETSM: NaviNet,SM the provider portal, is a HIPAA-compliant Web-based connectivity solution offered by NaviMedix,® Inc., that gives network providers access to quick and efficient ways to interact with AmeriHealth. Use NaviNetSM to connect with our back-end systems to streamline many of the daily administrative tasks associated with your patients’ health care. To increase efficiency in your office, we encourage you to use the NaviNetSM drug pre-authorization Plan transaction to streamline the submission of pre-authorization requests when prescribing any of the following medications to your patients:

office contact information and fax number. Confirmation numbers are presented upon submission of all complete drug-preauthorization requests to verify receipt by the Plan and determination is made within 48 hours. Notification of approved preauthorization is delivered to your office via the fax number supplied on the request. If preauthorization is not approved, a letter stating such is mailed to your office and the patient. All drug preauthorization submissions are available for tracking within the NaviNetSM referral/ authorization log for 13 months from the date of submission. Other NaviNetSM AmeriHealth Plan Transactions include, but are not limited to: Eligibility and Benefits Inquiry, Referral and Encounter Submission, Referral and Authorization Status Inquiry, Preauthorization Submission, Claim Status Inquiry, and the Provider Change Form.

Aciphex® / Actiq® / Amerge® / Amevive® / Avinza® / Axert® / Bextra® / Caverject® / Celebrex® / Cialis® / Codeine phosphate / Codeine sulfate / Demerol / Dilaudid / Edex® / Enbrel® / Endocet® / Endodan® / Forteo® / Frova® / Gleevec® / Humira® / Hydromorphone Investors in NaviMedix®, Inc. include an affiliate of AmeriHealth, which has a minority HCL / Imitrex® / Infant Formula / Kadian® / Kineret® / ownership interest in NaviMedix®, Inc. Levitra® / Levorphanol tartrate / Maxalt® / Meperidine HCL / Meperidine HCL/acetaminophen / Meperidine HCL/promethazine / Meperitab® / Meprozine® / Migranal® / Mobic® / Morphine sulfate / Morphine NaviNetSM eBusiness Provider InquiryLine sulfate IR / MS Contin / MSIR / Muse® / Oramorph i Registration or (856) 638-2701 in New Jersey SR® / Oxycodone HCL / Oxycodone/acetaminophen / Questions (302) 661-6111 in Delaware Oxycodone/ aspirin / Oxycontin® / OxyIR® / Percocet® /
Online Inquiry Form www.amerihealth.com/providers/navinet Percodan® / Percolone® / Prevacid / Prevacid Napra PAC® / Provigil® / Raptiva® / Relpax® / Roxicet® / Technical NaviMedix®, Inc. (888) 482-8057 Roxicodone® / Singulair® / Stadol® / Thalomid® / 8:00 a.m. to 8:00 p.m., EST, ? Assistance Tylox® / Viagra® / Xolair® / Zavesca® / Zomig® Use of this transaction will ensure all required information is received by the Plan for accurate and timely processing of your drug preauthorization requests, including your

for Existing NaviNetSM Users

U P D A T E

Simplify Drug Preauthorization

Monday through Friday, and 8:00 a.m. to 3:00 p.m., EST, Saturday

Member Eligibility Information Available Quickly and Efficiently The IVR is currently available for your HMO patients and PPO availability will follow shortly. You can access the IVR 24 hours a day, 7 days a week at (866) 681-7370. IVR can also fax requested information to your office. As a reminder, eligibility information is available for all members online through NaviNetSM. To get started on NaviNetSM, please contact the eBusiness Provider Inquiry Line at (856) 638-2701 in New Jersey or (302) 661-6111 in Delaware or complete an Online Inquiry Form at www.amerihealth.com/providers/navinet.

www.amerihealth.com

December 2004

You can now take advantage of our speech-enabled Interactive Voice Response (IVR) unit, an enhanced automated phone service formerly known as MEL (Member Eligibility Line). IVR allows you to speak into the phone when prompted in order to receive member eligibility information for your HMO patients. Within minutes you can obtain the member’s eligibility information without waiting on hold to speak to a service representative.

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IMPORTANT RESOURCES PROVIDER INFORMATION and TOOLS WEB PAGE www.amerihealth.com/providers PROVIDER MEDICAL POLICY WEB PAGE www.amerihealth.com/medpolicy PROVIDER ELECTRONIC DATA INTERCHANGE SERVICES WEB PAGE www.amerihealth.com/edi CORPORATE AND FINANCIAL INVESTIGATIONS DEPARTMENT Anti-Fraud and Corporate Compliance Hotline (866) 282-2707 www.amerihealth.com/anti-fraud CREDENTIALING COMPLIANCE HOTLINE (866) 282-2707 www.amerihealth.com/credentials

PROVIDER SERVICES Policies/Procedures/Claims HMO (800) 821-9412 NJ (800) 888-8211 DE PPO (800) 595-3627 NJ (800) 888-8211 DE PHARMACY SERVICES

HEALTH RESOURCE CENTER SM

AmeriHealth Healthy Lifestyles (800) 275-2583 Precertification (800) 227-3116

CARE MANAGEMENT AND COORDINATION (formerly Patient Care Management)

Prescription Drug Authorization (888) 671-5280

HMO Commercial (800) 373-4455 DE (800) 227-3116 NJ

Toll-Free Fax (888) 671-5285

PPO (800) 373-4455

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

Case Management (800) 373-4455 DE (800) 313-8628 NJ

Fax (215) 761-9165

Baby FootSteps® (800) 598-BABY [2229]

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

CONNECTIONSSM HEALTH MANAGEMENT PROGRAM PHYSICIAN HOTLINE and WEB PAGE (866) 866-4694 www.amerihealth.com/connections

The AmeriHealth Partners in Health Monthly Update is a publication of the Provider Communications department for the exchange of information and ideas among the AmeriHealth Provider community. Suggestions are welcome. Contact Information: Henna Remstein Managing Editor Elizabeth Derago Production Coordinator Provider Communications AmeriHealth 1901 Market Street, 35th Floor Philadelphia, PA 19103 Visit our website at www.amerihealth.com

PROVIDER SUPPLY LINE (800) 858-4728

POLICY Credentialing Compliance Hotline and Web Page Our corporate credentialing policy requires that our members receive in-network health care services only from fully credentialed, participating practitioners. As noted in your Professional Provider Agreement, non-credentialed practitioners may not see our members on an in-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.

View our online provider directories at www.amerihealth.com. 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 of products 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. 009189 2003-0269 12/03

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