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

August 2018GA-NL-0118-18

Table of ContentsMember’s Rights and Responsibilities Statement Page 2

Normal newborn diagnosis-related group claims processing update

Page 2

Coding Spotlight — Obesity Page 2Topical Corticosteroids Hot Tip Page 3Miscellaneous durable medical equipment billing guidelines Page 4

Services requiring prior authorization Page 5

Important information about utilization management Page 6

Electronic Data Interchange migration to Availity Page 6

Prior authorization requirements Page 7

OB Spotlight: Recognizing West Augusta Obstetrics and Gynecology

Page 8

Reimbursement Policies:Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Page 9

Medical Recalls Page 9

August 2018

Page 2 of 9

Normal newborn diagnosis-related group claims processing update

Effective November 1, 2018, Amerigroup Community Care will update the claims processing system to ensure accurate payment of newborn claims in accordance with Georgia normal newborn diagnosis-related group (DRG) requirements and our inpatient authorization requirements.

All newborn inpatient stays must have sufficient documentation provided to support an admission to an area beyond the newborn nursery, such as a neonatal intensive care unit (NICU) or for the higher level of care associated with the more complex newborn DRG. Documentation to support the higher level admission includes authorization or medical records.

Failure to provide the appropriate documentation will result in the claim being processed based on the normal newborn rate. Please note that current authorization guidelines for normal newborn and higher level of care baby inpatient stays will be applied.

For more information. reference the full provider update.GA-NL-0095-18

Coding Spotlight — Obesity

The obesity epidemic is a serious issue in the United States. The obesity rate is rising. Obesity has significant health consequences, contributing to increased rates in several diseases, including metabolic syndrome, high blood pressure, diabetes, heart disease, high blood cholesterol, sleep disorders and cancers.

For detail information on obesity HEDIS® measurements and coding, please view the full update on our provider website.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).GA-NL-0113-18

Member’s 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 to participating practitioners and members in our system, Amerigroup Community Care has adopted a Member’s Rights and Responsibilities Statement, which is located in your Provider Manual.

If you need a physical copy of the statement, call Provider Services at 1-800-454-3730.GA-NL-0117-18

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Topical Corticosteroids Hot Tip

This table is to assist prescribers in identifying topical corticosteroids included on the Amerigroup Community Care formulary. It does not represent all commercially available topical corticosteroids.

When prescribing medications, always select “substitution permissible by law” (where applicable) to ensure your patients are able to benefit from generic medications when available.

Therapeutic class Formulary productRelative cost per prescription*

Topical corticosteroids — low potency � Hydrocortisone Cream � Hydrocortisone Ointment $

Topical corticosteroids — medium potency � Triamcinolone Cream � Triamcinolone Ointment $

Topical corticosteroids — high potency � Fluocinonide-E Cream $$

Topical corticosteroids — very high potency

� Clobetasol Cream � Clobetasol-E Cream � Clobetasol Gel � Clobetasol Ointment

$$$

* Relative cost per prescription is intended to be directional in nature. Costs may change based on market dynamics. This information is meant to be used as a guide and should not take the place of clinical decision making by a prescriber regarding treatment.

Formulary status or drug availability may change. There may be additional qualifications needed for access to some drugs, such as a prior authorization or step therapy.

This document does not guarantee benefit coverage for any medication(s) as individual member coverage may vary.GA-NL-0090-18

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Miscellaneous durable medical equipment billing guidelines

Reminder: Miscellaneous durable medical equipment (DME) procedure codes (such as E1399) cannot be used as an alternative to specific identified codes. Amerigroup Community Care conducts postpayment reviews to ensure the right codes for the right services are used. This applies to all claims for Georgia Families members.

In an effort to improve the provider experience, we continually evaluate coding and billing patterns. Recently, we identified trends related to the use of E1399 — DME, miscellaneous. This code is only intended for use when a more appropriate code is not available. When an appropriate code does exist, that code must be used regardless of your contracted rate. It is not appropriate to use E1399 for payment increases.

We continue to require prior authorization for the use of miscellaneous code E1399.

To request PA, you may use one of the following methods: � Web: https://www.availity.com � Fax: 1-800-964-3627 � Phone: 1-800-454-3730

As it is not our policy to inform providers of proper billing processes within prior authorization responses, authorization responses do not include code-specific details. If your service was approved but your claim was denied payment when billed using E1399, the incorrect code was used. You will need to update the authorization and the claim with the appropriate HIPAA-compliant HCPCS code.

Amerigroup will conduct postpayment reviews of code E1399 to ensure proper use. If it is determined a more appropriate code should have been used, we will notify you in writing and advise you of your appeal rights.

You can find additional information related to miscellaneous codes in the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy at https://providers.amerigroup.com > Quick Tools > Reimbursement Policies > Medicaid/Medicare > Coding > Unlisted, Unspecified or Miscellaneous Codes.GA-NL-0100-18

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Services requiring prior authorization

All programs require prior authorization (PA) for specialty medications, where allowable by the state. The scope of this notice will include both professional and facility requests for Medicaid business.

Specialty medications that are reported with not otherwise classified (NOC) designation codes and C-codes may also require PA before services are provided.

Regardless of whether PA is required, all services must be medically necessary to be covered. Even if PA is not required, to avoid a claim denial based on medical necessity, Amerigroup Community Care encourages providers to review our medical necessity criteria prior to rendering nonemergent services. Medical necessity criteria can be accessed by visiting https://providers.amerigroup.com/GA to view the most current Medical Policies and Clinical Utilization Management Guidelines.

If no specific policy is available, the medical necessity review of a drug may be conducted using Medical Policy ADMIN.00006: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management Guideline and/or Clinical Utilization Management Guideline CG-DRUG-01: Off-Label Drug and Approved Orphan Drug Use.

Clinical review of specialty medications is in addition to services currently requiring PA. Providers are responsible for verifying eligibility and benefits for Amerigroup members before providing services. We recommend providers visit https://providers.amerigroup.com/GA to review the list of services and service categories currently requiring PA, with a reminder that the list of services requiring PA will be updated as needed. For clarification regarding whether a specific code or service requires PA, call the number listed below. Except in an emergency, failure to obtain PA may result in denial of reimbursement.

Again, please be reminded that the list of services requiring PA will be updated as needed.

Requesting PATo request PA, report a behavioral health admission or for questions regarding PA, providers may use one of the following methods:

� Web: https://www.availity.com � Fax: 1-800-964-3627 � Phone: 1-800-454-3730

For inpatient admissions with the exception of behavioral health, all should be placed on the Alliant/Georgia Medical Care Foundation portal at https://www.mmis.georgia.gov/portal/default.aspx.

Providers are strongly encouraged to revisit the Government Business Division Reimbursement Policy Unlisted or Miscellaneous Codes policy, which states NOC codes must be submitted with the correct national drug code (NDC) for proper claim payment. If the required NDC data elements are missing or invalid for the procedure code on a claim line, the claim will be denied.GA-NL-0097-18

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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, go to https://providers.amerigroup.com/GA > Provider Resources and Documents > QuickTools > Medical Policies.

We are staffed with clinical professionals who coordinate our members’ care and are available to accept precertification requests. 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 by logging in to https://providers.amerigroup.com/Pages/PLUTO.aspx and using the Precertification Lookup Tool.

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-0117-18

Electronic Data Interchange migration to Availity

Recently, Amerigroup Community Care partnered with Availity as our designated Electronic Data Interchange (EDI) gateway and E-Solutions Service Desk, and Amerigroup will not renew existing contracts with clearinghouse vendors. As a result, beginning January 1, 2019, Availity will manage all EDI trading partner relationships on behalf of Amerigroup. This new partnership will not interrupt your current services.

Transmitting 837 claimsIf you currently transmit 837 claims using a clearinghouse, you should contact your clearinghouse as soon as possible to confirm your EDI submission path for Amerigroup transactions has not changed. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Direct submitters can also use Availity for their 837 transmissions.

Registering with AvailityIf you choose to submit directly through Availity but are not yet a registered user, go to https://www.availity.com and select REGISTER. The registration wizard will lead you through the enrollment process. Once complete, you will receive an email with your login credentials and next steps for getting started. If you have any questions or concerns, please contact Availity at 1-800-AVAILITY (1 800-282-4548).

It is our priority to deliver a smooth transition to Availity for our EDI services. If you have questions, please contact your Provider Relations representative or Provider Services at 1-800-454-3730.GAPEC-2457-18

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Prior authorization requirements

Darzalex (daratumumab)

Effective August 1, 2018, prior authorization (PA) requirements will change for the injectable drug Darzalex (daratumumab) for Medicaid members.

PA requirements will be added to the following:

� Injection, Darzalex (daratumumab), 10 mg (J9145)

GA-NL-0099-18

Cabazitaxel (Jevtana)

Effective October 1, 2018, prior authorization (PA) requirements will change for the injectable drug Cabazitaxel (Jevtana) to be covered by Amerigroup Community Care.

PA requirements will be added to the following: � Cabazitaxel (Jevtana) — injection, 1 mg (J9043)

GA-NL-0101-18

Mepolizumab (Nucala) and reslizumab (Cinqair)

Effective September 1, 2018, prior authorization (PA) requirements will change for the injectable/infusible drugs mepolizumab (Nucala®) and reslizumab (Cinqair®).

PA requirements will be added to the following: � Mepolizumab (Nucala) — injection, 1 mg (J2182) � Reslizumab (Cinqair) — injection, 1 mg (J2786)

GA-NL-0104-18

Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

To request PA, you may use one of the following methods: � Web: https://www.availity.com � Fax: 1-800-964-3627 � Phone: 1-800-454-3730

Not all PA requirements are listed here. Detailed PA requirements are available to contracted and noncontracted providers on our provider website (https://providers.amerigroup.com/GA > Quick Tools > Precertification Lookup Tool). Providers may also call us at 1-800-454-3730 for PA requirements.

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OB Spotlight

Amerigroup Community Care would like to highlight and recognize West Augusta Obstetrics and Gynecology (West Augusta) for outstanding quality improvement in key performance areas!

From November 2016 to August 2017, West Augusta decreased their cesarean section (C-section) rate by 21.67 percent, a remarkable change they attribute to their dedication to staying current with the American College of Obstetricians and Gynecologists recommendations and guidelines, and through frequent and open teaching opportunities presented among the staff. For example, they work to educate their patients early on about the risks of a C-Section delivery and also educate themselves with best practice studies and clinical management changes to help prevent the low-risk primary C-section.

Within this same measurement period and as a result of their diligence and teamwork approach, West Augusta’s postpartum completion rate has increased by 114.14 percent. The OBs have focused heavily on patient education, discussing the importance of the postpartum visit early in the pregnancy and also helping patients decide which form of contraception they prefer to receive postpartum. Dr. John K. Trussell will even call from the hospital to help schedule the member’s postpartum appointment and ensure the contraceptive device of their choice has been ordered.

For scheduled inductions and C-sections, the postpartum visit is scheduled during the patient’s last prenatal appointment. The importance of the postpartum visit (and planning for it early) has been communicated and adopted by the entire staff, from the OBs to the nurses, to the schedulers and billers. The office staff works with the OB practice consultant and provider representative regularly to ensure they are scheduling their delivered patients within the correct time frame and that their efforts are being reflected correctly in their billing and charting.

Please join us in congratulating the physicians and staff at West Augusta Obstetrics and Gynecology for their hard work and outstanding results!GA-NL-0102-18

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Reimbursement Policies

Policy Update Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service (Policy 06-003 — effective 09/01/2018)

The Amerigroup Community Care Modifier 25 reimbursement policy provides the criteria for reimbursement for a significant, separately identifiable evaluation and management (E&M) service performed by the same provider on the same day of the original service or procedure. Effective September 1, 2018, Amerigroup does not allow separate reimbursement for E&Ms performed on the same day as a major surgery (90-day global period).

For additional information, refer to the Modifier 25 reimbursement policy at https://providers.amerigroup.com > Quick Tools > Reimbursement Policies > Medicaid/Medicare > Coding.GA-NL-0073-17

Policy UpdateMedical Recalls(Policy 06-111 — effective 11/01/2018)

In applicable circumstances, the appropriate modifier, condition code or value code (identified below) should be used to identify a medically recalled item. This will assist Amerigroup Community Care in identifying medically recalled items and support correct coding guidelines.

Applicable condition codes are 49 and 50. Condition code 49 signifies products replaced within the product lifecycle due to the product not functioning properly, and condition code 50 is used for product replacement for known recall of a product.

When a credit or cost reduction is received by the provider for the replacement device, applicable modifiers are FB and FC. Modifier FB is used when items are provided without cost to the provider, supplier or practitioner, and modifier FC is used when a partial credit is received by the provider, supplier or practitioner for the replacement device.

Note: In circumstances where we have reimbursed the provider for repair or replacement of items or procedures related to items due to a medical recall, we are entitled to recoup or recover fees from the manufacturer and/or distributor as applicable. In circumstances where we have reimbursed the provider the full or partial cost of a replaced device and the provider received a full or partial credit for the device, we are entitled to recoup or recover fees from the provider.

Please refer to CMS and/or your state’s guidelines, and the Medical Recalls reimbursement policy for additional details at https://providers.amerigroup.com/GA > Quick Tools > Reimbursement Policies > Medicaid/Medicare.GA-NL-0089-18