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Provider Newsletter

Coverage provided by Amerigroup Inc.

June 2019NM-NL-0043-19

Table of Contents2019 Utilization Management Affirmative Statement concerning utilization management decisions

Page 2

Medical records request for risk adjustment Page 2

Partial hospitalization services Page 2

Submitting corrected claims Page 3

Outpatient Rehabilitation Program transitioning to AIM Page 4

Update: 2019 risk adjustment provider trainings Page 5

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

Page 6

Home health billing guidelines for contracted providers Page 6

Medical Policies and Clinical Utilization Management Guidelines update

Page 7

Fall prevention tips Page 7

Prior authorization requirements Page 8

June 2019

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Medical records request for risk adjustment

Amerigroup Community Care of New Mexico, Inc. is working with Optum CiOX Health (CiOX) to request medical records for risk adjustment. Risk adjustment is the process by which CMS reimburses Medicare Advantage plans, such as Amerigroup, based on the health status of their members. Risk adjustment was implemented to pay Medicare Advantage plans more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (age and gender), as well as health status.

In 2019, Amerigroup will work with Optum, using their copy partner CiOX, to request medical records with dates of service for the target year 2018, through present day, then review and code the record.

Jaime Marcotte, Retrospective Risk Program Lead, is managing this initiative. Should you have any questions regarding this program, please contact Jaime at Jaime.Marcotte@anthem.com or 843-666-1970.

Read more online.

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Partial hospitalization services

Medicare Advantage plans under Amerigroup Community Care of New Mexico, Inc. follow original Medicare guidelines and billing requirements for partial hospitalization services. CMS regulations (42 CFR 410.43(c)(1)) state that partial hospitalization programs (PHPs) are intended for members who require a minimum of 20 hours per week of therapeutic services as evidenced in their plan of care. All partial hospitalization services require prior authorization.

Read more online.

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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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2019 Utilization Management Affirmative Statement concerning utilization management decisions

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Submitting corrected claims

Amerigroup Community Care of New Mexico, Inc. will treat corrected claims as replacement claims. When you submit a corrected claim, it is important that you clearly identify that the claim is a correction rather than an original claim. Refer to the instructions below for information on submitting CMS-1500 and UB-04 claims forms.

Electronic CMS-1500 claims Enter Claim Frequency Type code (billing code) 7 for a replacement/correction. Enter 8 to void a prior claim in the 2300 loop of CLM*05 03. Enter the original claim number in the 2300 loop of the REF*F8*.

Paper CMS-1500 claimsAmerigroup will accept:

� Corrected claim written on the face of the CMS-1500 claim. � The Provider Adjustment Request Form clearly identifying the information being

corrected. � Entry in box 22 of the claim:

� Use resubmission code 7 to notify us of a corrected or replacement claim. � Insert an 8 to let us know you are voiding a previously submitted claim. � Enter the original claim number in the Original Ref. No. field. If that information

is not available, enter the original document control number (DCN).

Electronic or paper UB-04 claims � Amerigroup will continue to accept the Provider Adjustment Request Form clearly identifying the

information being corrected. � When submitting a corrected claim, ensure the type of bill is xx7 (correction/replacement) or xx8 (void)

when the correction is made within the initial claim one year timely filing limitation.

When you need to correct a claim and it is beyond the timely filing limit of one calendar year from the through date on claim, you should submit a reopening request (type of bill XXQ) to correct the error. Reopenings are typically used to correct claims with clerical errors, including minor errors and omissions, and are conducted at the discretion of the plan. Therefore, it is not appealable and the original initial determination stands as a binding decision. Appeal rights are retained on the original initial determination. Omissions do not include failure to bill items or services such as late charges.

Note: For adjustments and reopenings that result in higher weighted diagnosis-related groups there is a congressionally mandated time frame of 60 days from the initial claim determination.AGPCRNL-0015-19

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Outpatient Rehabilitation Program transitioning to AIM

Effective October 1, 2019, Amerigroup Community Care of New Mexico, Inc. will transition utilization management of our Outpatient Rehabilitation Program for Medicare Advantage from OrthoNet LLC to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. Amerigroup has an existing relationship with AIM in the administration of other programs.

This transition enables Amerigroup to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Amerigroup for medical necessity determination. For Medicare Advantage, Amerigroup makes coverage determinations based on guidance from CMS including national coverage determinations, local coverage determinations, other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

AIM will continue to use criteria documented in Amerigroup clinical guidelines GC.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed in Availity by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.

Detailed prior authorization requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at https://www.availity.com. Contracted and noncontracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.

Prior authorization review requirementsFor services scheduled to be rendered through September 30, 2019, providers must contact OrthoNet LLC to obtain prior authorizations for outpatient rehabilitation services. Any authorizations OrthoNet LLC makes prior to the transition date of October 1, 2019, will be honored and claims will process accordingly.

For services that are scheduled on or after October 1, 2019, providers must contact AIM to obtain prior authorization. Beginning September 15, 2019, providers will be able to contact AIM for prior authorization on services to take place on or after October 1, 2019. Providers are strongly encouraged to verify that they have obtained prior authorization before scheduling and performing services.

How to place a review requestYou may place a request online via the AIM ProviderPortalSM. This service is available 24/7 to process requests in real time using clinical criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday-Friday 7 a.m.-7 p.m. Central time.

For more informationFor resources to help your practice get started with the Outpatient Rehabilitation Program, go to www.aimproviders.com/rehabilitation. Our provider website helps you learn more and provides access to useful information and tools such as order entry checklists, clinical guidelines and FAQ.AGPCRNL-0024-19

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Update: 2019 risk adjustment provider trainings

Our Medicare Risk Adjustment regulatory compliance team offers two provider training series regarding Medicare risk adjustment guidelines. Information for each training is outlined below.

Medicare Risk Adjustment and Documentation Guidance (General) trainingSeries: Offered the first Wednesday of each month from 1 p.m.-2 p.m. ET

Learning objective:

Provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding

Credits: This live activity is offered from December 5, 2018-November 6, 2019. It has been reviewed by the American Academy of Family Physicians and is acceptable for up to 1.00 prescribed credit.

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below: https://antheminc.adobeconnect.com/admin/show-event-catalog?folder-id=38826374.Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific) trainingSeries: Offered bimonthly on the fourth Wednesday from noon-1 p.m. ET

Learning objective:

Collaborative learning event with enhanced personal health care to provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding HCCs, with guidance on documentation and coding

Credits: This live activity series is offered from January 23, 2019-November 27, 2019. It has been reviewed by the American Academy of Family Physicians and is acceptable for credit.

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates to register for below: 1. Red Flag HCCs, Part 1 (Register for recording of live session): Training will cover HCCs most commonly

reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration. https://antheminc.cosocloud.com/e4i5k4h7cf3j/event/registration.html

2. Red Flag HCCs, Part 2 (March 27, 2019): Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration. https://antheminc.cosocloud.com/enfndbyedd5g/event/event_info.html

3. Opioids and more: Substance abuse and dependence (May 22, 2019): Register at https://antheminc.cosocloud.com/ej8ltgkxa1ch/event/registration.html.

4. Acute, chronic and status conditions (July 24, 2019): Register at https://antheminc.cosocloud.com/e2j034x8nshx/event/registration.html.

5. Diabetes mellitus and other metabolic disorders (September 25, 2019): Register at https://antheminc.cosocloud.com/e9l4sxzbd2lq/event/registration.html.

6. Behavioral health (November 27, 2019): Register at https://antheminc.cosocloud.com/eatxsocnqf6h/event/registration.html.

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Home health billing guidelines for contracted providers

This information is intended for providers who do not submit their claims to MyNexus.

Below are some billing guidelines we recommend home health providers use when billing a Request for Anticipated Payment (RAP) and final claim to Amerigroup Community Care of New Mexico, Inc. This information will assist home health providers in receiving the correct and timely payment according to Medicare guidelines and their contract.

� Amerigroup should receive the final bill within 120 days after the start date of the episode or 60 days after the paid date of the RAP claim — whichever is greater. If the final bill is not received within this time frame, the RAP payment will be canceled/recouped — This is a Medicare billing requirement.

� Bill the full Medicare allowed amount for the episode as the billed charges. Do not bill only the expected additional payment on the final claim as the billed charges. When this happens, the Lesser of Logic term in your contract affects the final payment made for the services. If the billed charges are less than the final allowed, the payment will be reduced to only pay up to the billed charges. The billed charges on the final claim should be for at least the full Medicare allowed amount for the services rendered. This will allow the claim to process correctly according to Medicare guidelines.

� Example: RAP claim paid $500. The final claim is submitted with billed charges in the amount of $1,000. The Medicare allowed amount is $1,500. Since the billed charges on the final claim are only $1,000, Amerigroup would only pay an additional $500 for the final allowed according to the Lesser of Logic term in the contract. If the provider would have billed charges in the amount of at least $1,500, then an additional payment of $1,000 would have been paid.

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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 a 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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Fall prevention tips

Each year, falls result in more than 2.8 million ER visits, 800,000 hospitalizations and 27,000 deaths. Additional information about helping patients enrolled in Amerigroup Amerivantage (Medicare Advantage) prevent falls is available online.AGPCRNL-0011-19

Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits; they should be followed in the absence of Medicare guidance. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

To search for specific policies or guidelines, visit https://medicalpolicies.amerigroup.com/am_search.html.

Updates: � MED.00110 — Growth Factors, Silver-Based

Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting was revised to add bioengineered autologous skin-derived products (for example, SkinTE) as investigational and not medically necessary.

� MED.00126 — Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders was revised to add nasal nitric oxide as investigational and not medically necessary in the diagnosis and monitoring of asthma and other respiratory disorders.

� SURG.00037 — Treatment of Varicose Veins (Lower Extremities) was revised to replace “non-surgical management” with “conservative therapy” in the medically necessary criteria and to add sclerotherapy used in conjunction with a balloon catheter (for example, KAVS procedure) as investigational and not medically necessary.

� TRANS.00035 — Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases (Previous title: Mesenchymal Stem Cell Therapy For Orthopedic Indications) was revised to expand the scope to address non-FDA-approved uses of mesenchymal stem cell therapy; the position statement has been revised to the following: “Mesenchymal stem cell therapy is considered INV & NMN for the treatment of joint and ligament disorders caused by injury or degeneration as well as autoimmune, inflammatory and degenerative diseases.”

� The following AIM Specialty Health® updates took

effect on January 24, 2019: Advanced Imaging (imaging of the heart and imaging of the head and neck), Arterial Ultrasound and Joint Surgery.

Medical Policies On January 24, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup Community Care of New Mexico, Inc. View the full update online for a list of the policies.

Clinical UM Guidelines On January 24, 2019, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. These guidelines were adopted by the medical operations committee for Medicare Advantage members on March 28, 2019. View the full update online for a list of the guidelines.

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Read more online.

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DME repair and portable oxygen concentrator

Effective July 1, 2019, prior authorization (PA) requirements will change for for DME repair and portable oxygen concentrators to be covered by Amerigroup Community Care of New Mexico, Inc.

PA requirements will be added to the following: � K0739 — Repair or nonroutine service for durable medical equipment other than oxygen requiring the skill

of a technician, labor component, per 15 minutes � E1392 — Portable oxygen concentrator, rental

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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

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal. Providers may also call the Provider Services number on the back of the member’s ID card for PA requirements.

Prior authorization requirements