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Ancillary

January 2009

INSIDE THIS ISSUEICD-10

Update on ICD-10 timeframe �

MANUAL UPDATES A new � Hospital Manual is coming soon (NJ only)

BILLINGLaboratory services reminder �

Laboratory services clarification for Level I, II, and III outpatient �laboratory testing services

Reminder: claims submitted without a valid, registered NPI will reject �

Reminder: important messages on your SOR (NJ only) �

PRODUCTS Reminder: AmeriHealth 65 � ® Basic plan is discontinued (PA only)

MEDICALReminder: new look for member ID cards (PA only) �

Policy notifications posted as of December 16, 2008 �

Medicare members must receive notice of noncovered/excluded �services and member payment responsibility (PA and NJ only)

Reminder: changes to precertification requirements for most outpatient �mental health services (PA and DE only)

Reminder: referrals not needed for services provided through Direct �Access OB/GYNSM

Timely submission of maternity patient questionnaires important for �early outreach

Reminder: transition to all-electronic authorization inquiry and �submission continues

SPECIALTY PHARMACY Important changes about self-injectable drug coverage coming �January 1, 2010

Valid NDC required on claims submitted for drugs (e.g., J codes and �other drug codes)

APPEALS Mandated provider claim appeals process (NJ only) �

PREVENTIVE HEALTH SMART � ® Registry release for January 2009

Connections � SM Health Management Programs: supporting our members, your patients

Keep your information up to dateHave you made any changes to your key practice information, such as your mailing address or the name of your practice? If so, please be sure to notify us.

We value your help in keeping our data files current. Accurate data files allow us to continue to provide you with important information on billing, claims, changes or additions to policies, and announcements of administrative processes.

You may submit this information to us electronically via the Provider Change Form, which is available on www.amerihealth.com/providers/forms, or through NaviNet®.

You may also call your Network Coordinator or Customer Service to report changes.

Please note: Thirty days’ advance notice is required for processing.

www.amerihealth.com/providersJanuary 20092

ICD-10

Update on ICD-10 timeframe

The U.S. Department of Health and Human Services (HHS) recently announced a new regulatory requirement for health plans and providers to transition from the currently used ICD-9 to the new ICD-10. We want to bring you up to date on recent activities surrounding this requirement.

Under the current proposal, health plans and providers will be required to fully implement ICD-10 by October 1, 2011; however, due to the extensive changes providers will need to make to their business practices to accommodate this requirement, several efforts have been made to demonstrate the need for an extension of the implementation date.

We, along with the American Medical Association (AMA) and nearly all state medical societies, have urged HHS to give the industry more time to transition to ICD-10 in its final regulation. Specifically, we support the timeframe as

recommended by the National Committee on Vital and Health Statistics (NCVHS), a key advisory body to HHS, that allows: two years to complete the second generation of nine HIPAA transactions (“5010”) – a prerequisite to ICD-10 – before beginning work on ICD-10 (not simultaneously); and an additional three years to complete ICD-10. If the NCVHS process was followed and started now, the soonest ICD-10 could be completed is late 2013.

A coalition of provider organizations in Washington has worked closely with HHS officials requesting the need for a workable timeframe for this transition. In addition, the AMA, along with a majority of state medical societies has urged the HHS to give the industry more time to complete this transition. We support this recommendation.

Please visit our site www.amerihealth.com/providers/icd_10 frequently for updated information on ICD-10.

manual upDates

A new Hospital Manual is coming soon (NJ only)

An updated Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual) will soon be available through NaviNet®. The new Hospital Manual has been enhanced, expanded, and updated to include valuable resources and necessary information regarding our policies, procedures, and programs not only for hospitals, but for ancillary facilities and ancillary providers as well. This comprehensive new Hospital Manual is a complete replacement of the prior Hospital Manual, 2002 edition, as revised. It also replaces any ancillary provider-specific provider manual, such as the Ambulatory Surgical Center, Renal Dialysis Center, Skilled Nursing Facility, Home Health Agency, Durable Medical Equipment, and Home Infusion Provider Manuals. The Provider Manual for Participating Professional Providers remains unchanged and is also available through NaviNet.

You will be able to access the Hospital Manual through easy-to-navigate PDFs that are organized into color-coded sections. Within those sections are links that will take you to important information, such as our Companion Guides, with a simple click of your mouse.

Manual name change for hospitals, ancillary facilities, and ancillary providersThe reference to “Hospital Manual” or “Provider Manual” as defined in current AmeriHealth Hospital Participation Agreements, AmeriHealth Managed Care Ancillary Facility Agreements or other AmeriHealth Managed Care Ancillary Provider Agreements, shall apply to this comprehensive “Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers.” References to “Hospital Manual” or “Provider Manual” in AmeriHealth Hospital Participation Agreements, AmeriHealth Managed Care Ancillary Facility Agreements or other AmeriHealth Managed Care Ancillary Provider Agreements remain unchanged.

If you do not have access to NaviNet, you may request a print version of either the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers or the Provider Manual for Participating Professional Providers by calling the Provider Supply Line at 1-800-858-4728.

www.amerihealth.com/providersJanuary 20093

billing

Laboratory services reminder

We encourage professional providers to set up accounts with designated laboratory sites to accommodate testing needs, improve record-keeping, promote communication between the laboratory and the physician, and facilitate timely receipt of laboratory supplies. Keep in mind that any referral to a nonparticipating laboratory or nonparticipating provider requires preapproval/precertification from AmeriHealth.

For more information for professional providers designating a laboratory site, please look in the Provider Manual for Participating Professional Providers under Laboratory Services in the Specialty Programs and Laboratory Services section. You can find the laboratory indicator on the front of the member ID card, on NaviNet®, and/or the nteractive Voice Response (IVR) system. Please refer to the following list of participating contracted laboratories for outpatient services:

Laboratory name Laboratory indicator Phone number

Abington Memorial Hospital Laboratory Abington 215-481-2331

Health Network Laboratories HNL 1-877-402-4221

Hospital of the University of Pennsylvania Laboratory* UPHS 1-800-789-7366

Laboratory Corporation of America Lab Corp 1-866-297-3210

Mercy Health Laboratory Mercy 610-237-4175

Quest Diagnostics, Inc. Quest 1-800-825-7320

SMA Medical Laboratories SMA 215-322-6590

Thomas Jefferson University Laboratory* Jefferson 215-955-6545

*Available to specific practices only

Specialized pathology testing is offered by the designated laboratories as well as by the following specialized participating laboratory providers:

Laboratory name Specialty Phone number

AmeriPath New York, Inc. Dermatopathology only 1-800-553-6621

CBLPath Dermatopathology/pathology 1-877-225-7284

DIANON Systems, Inc. Dermatopathology/pathology 1-800-328-2666

Genomic Health Oncotype DX® only 1-866-662-6897

Genzyme Genetics Reproductive/Genetic/Oncology testing only

1-800-848-4436 (Reproductive and genetic testing)

1-800-447-5816 (Oncology testing)

Institute for Dermatopathology Dermatopathology only 610-260-0555

Litholink Kidney stone prevention 1-800-338-4333

Monogram Biosciences, Inc. Trofile™ Co-Receptor tropism assay only 650-635-1100

Myriad Genetics BRACAnalysis, COLARIS® and COLARIS AP® only 1-800-469-7423

Penn Cutaneous Pathology Dermatopathology only 1-866-337-6522

continued on page 4

www.amerihealth.com/providersJanuary 20094

bIllIng

Laboratory services reminder (continued)

Home phlebotomy may be available when members are homebound. Services may be arranged by contacting one of the contracted home phlebotomy providers listed at right. Some designated laboratories also offer home phlebotomy for patients who reside in assisted-living or non-skilled nursing homes. This service is covered only as defined by Medicare Guidelines. Medicare Guidelines are applied for all members regardless of coverage.

We have contracted with Brookside Clinical Labs and Professional Technicians to perform home phlebotomy services for all members. These providers will perform the home draw only and deliver the sample to a participating designated laboratory (HMO) or participating laboratory/hospital (PPO).

Laboratory name Phone number

Brookside Clinical Labs 610-872-6466

Professional Technicians 215-364-4911

HMO/POS: All routine laboratory services for HMO/POS members must be directed to and processed by the PCP’s designated laboratory site.

This is not a statement of benefits. Benefits may vary based on state requirements, Benefit Program (HMO, PPO, etc.), contract, or employer group. Individual member coverage must be verified with AmeriHealth. Please contact Customer Service for more information on specific benefit coverage.

We would like to take this opportunity to reiterate our policy regarding Level I, II, and III outpatient laboratory services provided in the physician office.

The “Specialty Programs and Laboratory Services” section of the October 2007 Provider Manual for Participating Professional Providers states:

Covered Level I and Level II outpatient laboratory �tests may be performed in the physician’s office. If a laboratory test is not listed as Level I or Level II, it is considered a Level III test. Level III outpatient laboratory tests must be referred to a commercial laboratory or one of the network hospitals that have contracted with AmeriHealth PPO to perform outpatient laboratory services. If using a commercial laboratory, a requisition form from the lab must be completed.

Home phlebotomy services may be arranged by �contacting a contracted home phlebotomy provider. Some designated labs also offer home phlebotomy for patients living in assisted living or non-skilled nursing homes. This service is covered only as defined by Medicare Guidelines. Medicare Guidelines are used for all Members regardless of coverage.

We also want to remind you that if you are a participating physician provider, you may bill only for covered services that you or your staff perform. Participating physician provider offices are not permitted to submit claims for services that they have ordered but that have not been rendered (also known as “pass-through” billing). Pass-through billing of laboratory services performed by a contracted or noncontracted laboratory is not reimbursable.

For a list of participating clinical laboratories in our network, please refer to the article on page 3, or the “Specialty Programs and Laboratory Services” section of the Provider Manual. Please call Customer Service or contact your Network Coordinator or Hospital/Ancillary Services Coordinator with any questions.

For more information regarding Level I, II, and III outpatient laboratory testing services, please see the Pennsylvania Limited Survey Survival Guide at www.dsf.health.state.pa.us/health/cwp/view.asp?a= 167&q=202583 or Understanding clinical laboratory regulations in Pennsylvania, as they apply to physician office laboratories at www.dsf.health.state.pa.us/health/lib/health/labs/understanding_clinical_laboratory_regulations_107.ps.pdf.

Laboratory services clarification for Level I, II, and III outpatient laboratory testing services

www.amerihealth.com/providersJanuary 20095

bIllIng

Reminder: claims submitted without a valid, registered NPI will reject NPIs must be registered with AmeriHealthAs previously communicated, claims submitted to us without a registered NPI began rejecting as of May 23, 2008, per the Centers for Medicare & Medicaid Services mandate. NPIs can be registered online by submitting an NPI provider registration web form at www.amerihealth.com/providers/npi/provider_registration.html.

Claims submitted with invalid NPIs will rejectEach claim must pass an NPI check-digit validation to ensure that it has a valid NPI. To date, some claims are still not passing this check-digit validation. The most common reasons why claims are not passing the NPI check-digit validation are:

The wrong provider identifier is entered in an NPI �field.

The NPI is entered incorrectly. �

The number entered is not a valid NPI. �

Processing of claimsFor purposes of processing a claim in accordance with the reimbursement terms of your provider contract, you may continue to provide your 10-digit legacy number in addition to your valid, registered NPI. The sole purpose for providing the 10-digit legacy number is to facilitate accurate claims payment — not to identify the claim for acceptance into our system. Only a valid NPI will be accepted by us as the primary identifier on the claim.

If you need more information about NPI claims submission, please refer to our National Provider Identifier (NPI) Toolkit: Tips for Proper Electronic and Paper Claims Submission, located at www.amerihealth.com/pdfs/providers/npi/toolkit.pdf.

Learn more about NPIs. Our previous communications, FAQs, and additional resources are available at www.amerihealth.com/providers/npi.Please note: We will receive contracted behavioral health providers’ NPI information directly from Magellan Behavioral Health, Inc. For more information, please contact Magellan National Provider Services Center at 1-800-788-4005, or visit Magellan at www.magellanhealth.com.

Reminder: important messages on your SOR (NJ only)

As a reminder, please review your statement of remittance (SOR) for updated claims and billing-related messages. You can also find updates on our website at www.amerihealth.com/providers/claims_and_billing/claim_requirements.html.

www.amerihealth.com/providersJanuary 20096

proDuCts

Reminder: AmeriHealth 65® Basic plan is discontinued (PA only)As of January 1, 2009, AmeriHealth HMO, Inc. no longer offers the AmeriHealth 65 Basic plan. We took several steps to ensure that all affected members received adequate time and information to obtain new health care coverage before January 1, 2009. The information included:

List of alternate health plans. � AmeriHealth 65 Basic members were sent a list of alternate health care plans to replace their AmeriHealth 65 Basic coverage. AmeriHealth 65 Basic providers were sent this list as well to assist their patients with their transition. Members who did not select a new health care plan before January 1, 2009, were automatically enrolled in Original Medicare.

Posters. � Informational posters about the discontinuation were distributed to hospitals, doctors’ offices, and group homes.

Public forums. � We placed several announcements in regional newspapers to notify the affected five counties of the discontinuation of this health plan. Town hall meetings were also held for members to learn more about their health care options after the discontinuation.

If you have any further questions about the discontinuation of AmeriHealth 65 Basic, please contact your Network Coordinator.

meDICal

Reminder: new look for member ID cards (PA only)

ID cards for some Pennsylvania members have a new look. The new cards are issued to members when a change, such as choosing a new primary care physician (PCP), adding a dependent, or renewing benefits, is made to their coverage. Until such a change is made, members will continue to use their current card.

The new design divides the front of the card into four quadrants, each separated by a horizontal line. Each quadrant contains information specific to the member, such as member name and ID number, PCP information, and cost-sharing information.

The back of the card provides important telephone numbers. To simplify the process of obtaining information on our members, providers can now use one number, 1-800-275-2583, to request precertification for covered services and obtain eligibility information. NaviNet® is also available to confirm member eligibility.

If you have questions about the new ID cards, please contact your Network Coordinator.

Notes: New cards will go into effect for AmeriHealth New Jersey and Delaware members in 2009. We will provide more information as it becomes available.

For behavioral health services, providers should still call the number on the member’s ID card under Mental Health/Substance Abuse.

front back

www.amerihealth.com/providersJanuary 20097

Policy notifications posted as of December 16, 2008

In order to better inform you, we have developed a Policy Notifications web page where our policies are posted prior to their effective date. Below is a listing of the policy notifications posted to the site as of December 16, 2008.

Policy effective date Notification title Notification issue date

January 1, 2009 08.00.26h Botulinum Toxin Type A and Type B October 1, 2008

January 1, 200904.00.05b Extraction of Bony Impacted Teeth and Exposure of Impacted

TeethOctober 1, 2008

January 1, 2009 08.00.76 Oxaliplatin (Eloxatin®) October 1, 2008

January 1, 2009 00.01.44 Never Events and Preventable Adverse Events December 10, 2008

January 9, 2009 11.08.19f Prophylactic Mastectomy December 10, 2008

January 13, 2009 05.00.25e Cranial Remolding Orthoses (Helmets) October 15, 2008

January 13, 2009 05.00.21c Durable Medical Equipment (DME) October 15, 2008

January 21, 2009 08.00.56a Treatment of Autism with Secretin December 4, 2008

January 27, 2009 11.08.08d Chemical Peels October 29, 2008

January 27, 2009 11.08.29c Procedures for the Treatment of Acne October 29, 2008

January 27, 2009 11.08.25a Scar Revision October 29, 2008

January 27, 2009 11.08.04d Selective Photothermolysis Using Pulsed-Dye Lasers (PDL) October 29, 2008

January 27, 2009 11.08.20c Wound Care: Bioengineered Skin Substitutes October 29, 2008

February 10, 200911.03.11e Procedures for the Treatment of Gastroesophageal Reflux

Disease (GERD)November 12, 2008

February 11, 2009 07.02.05e External Counterpulsation (ECP) November 12, 2008

February 24, 2009 07.03.14d Intraoperative Neurophysiological Monitoring (INM) November 26, 2008

February 25, 2009 11.14.23 Femoroacetabular Surgery November 26, 2008

March 1, 2009 00.03.02f Diagnostic Radiology Services Included in Capitation December 1, 2008

March 17, 2009 05.00.35a Foot Orthotics and Other Podiatric Appliances November 12, 2008

March 17, 2009 05.00.59b Lower Limb Prostheses November 12, 2008

March 17, 2009 05.00.11b Therapeutic Shoes and Orthopedic Shoes November 12, 2008

To access these notifications and view the policies in their entirety, follow these instructions:

Visit 1. www.amerihealth.com/medpolicy. Select 2. Accept and Go to Medical Policy Online.Select 3. Policy Notifications from the Medical Policy column on the left sidebar.

Be sure to check back often, as the site is updated frequently.

meDICal

www.amerihealth.com/providersJanuary 20098

meDICal

Medicare members must receive notice of noncovered/ excluded services and member payment responsibility (PA and NJ only)Providers must furnish AmeriHealth 65® members with written notice before providing noncovered/excluded services that the services are not covered and the members will be responsible for payment. Examples of noncovered/excluded services include, but are not limited to:

comfort and convenience items, such as a total electric �hospital bed;

equipment inappropriate for home use, such as a �standing frame system;

equipment that is not primarily medical in nature, �such as, some power wheelchair accessories, such as power seat elevation system, power standing feature, and remote operation;

equipment with features of a medical nature that are �not required by the individual’s condition, such as a water-circulating cold pad with pump;

other examples include non-elastic binders or gradient �compression stockings (HCPCS codes A6530; A6533-A6549).

This requirement for written notification of noncovered/excluded services and payment responsibility is contained in Section 2.10 of the Professional Group Provider Agreement (or 2.9 of the Professional Provider Agreement), which provides that in the event the Provider provides

excluded services to the Beneficiary, the Provider must inform the Beneficiary in advance, in writing: (i) of the service(s) to be provided; (ii) that AmeriHealth will not pay for or be financially liable for said services; and (iii) that the Member will be financially liable for such services.

If the provider does not give written notice of noncovered services to the member, he or she is required to hold the member harmless.

The approved form of the Centers for Medicare & Medicaid Services, Notice of Denial of Medical Coverage, is included within this issue of Partners in Health Update and may be used when the member requests services that are not covered because the services are not Medicare-covered benefits. This easy-to-use form requires the provider to list the item or service that is not covered and the reason for the noncoverage decision. Generally, the reason for noncoverage should be that Medicare does not cover the item or service. A copy of the form should be given to the member and a copy should be made part of his or her medical record. The form also provides the member with appeal rights.

Please visit www.amerihealth.com/medpolicy for more information about noncovered services.

Reminder: changes to precertification requirements for most outpatient mental health services (PA and DE only)As of January 1, 2009, we have eliminated the requirement for providers to obtain precertification and continuing authorizations for routine and medication management outpatient mental health services under most AmeriHealth benefits plans.

Magellan Behavioral Health, Inc., which manages the behavioral health (mental health and substance abuse) benefits for the majority of AmeriHealth plans, communicated this change to its mental health providers

prior to the effective date. Please note that precertification requirements that were previously in place for substance and alcohol abuse services, mental health inpatient services, partial hospitalization programs, and intensive outpatient programs will continue to be required.

Note: Magellan Behavioral Health, Inc. manages mental health and substance abuse benefits for most members. When HMO/POS and PPO members receive services from Magellan Behavioral Health, Inc. providers, the provider will be responsible for obtaining any required precertifications.

www.amerihealth.com/providersJanuary 20099

meDICal

Reminder: referrals not needed for services provided through Direct Access OB/GYNSM

Direct Access OB/GYN allows HMO/POS members to receive certain services from any network obstetrical/gynecological (OB/GYN) specialist or subspecialist without a referral for preventive care visits, routine OB/GYN care, or problem-related OB/GYN conditions.

Specialties and subspecialties not requiring referrals include, but are not limited to, the following:

OB �GYN (including urogynecologist) �OB/GYN �gynecologic oncologist �reproductive endocrinologist/infertility specialist �maternal fetal medicine/perinatologist �midwife �

Services not requiring referrals from primary care physicians (PCP) or OB/GYNs include, but are not limited to, the following:

all antenatal screening and testing �fetal or maternal imaging �hysterosalpingogram/sonohysterogram �

You must continue to use the OB/GYN Referral Request Form for the following services:

pelvic ultrasounds, abdominal X-rays, intravenous �pyelograms (IVP), and DEXA scans (these tests must be performed at the member’s capitated radiology site);

initial consultations for HMO members �for endocrinology, general surgery, genetics, gastrointestinal, urology, pediatric cardiology, and fetal cardiovascular studies (visits beyond the initial consultation still require a PCP referral).

Please remind your patients about the referral requirements and contact your Network Coordinator or Hospital/Ancillary Services Coordinator with any questions.

Timely submissions of maternity patient questionnaire important for early outreachRegistering maternity members into our Baby FootSteps® high-risk perinatal program is imperative for early outreach. The Initial Maternity Patient Questionnaire form should be mailed immediately after the first prenatal visit to ensure timely registration into this programs. In some instances, forms are being batched and mailed at a later date — our goal, however, is to reach out to members identified as having risk factors within the first trimester of pregnancy.

The program offers many benefits to members, such as educational materials and coupons for parenting classes, lactation consultants, and breast pumps. Additionally, our

obstetric nurses offer case management to members who need help with such diagnoses as:

gestational diabetes mellitus �pregnancy-induced hypertension �pre-term labor �hyperemesis gravidarum �

Please remind your staff to send in the registration forms immediately after the first prenatal visit. Member registration into the program and prenotification for delivery will be completed at the same time.

www.amerihealth.com/providersJanuary 200910

meDICal

Reminder: transition to all-electronic authorization inquiry and submission continuesNew enhancements to the provider interactive voice response (IVR) system will be launched soon. These enhancements will provide you with the ability to submit electronic authorization or precertification requests for outpatient and office medical and/or surgical procedures.* This service will be directly accessible through Customer Service at 1-800-275-2583, prompt 2 for Provider Services.

The updated system will be available soon as part of our phased approach toward an all-electronic format for authorization inquiry and submissions. When making a request with the updated system, the following information is required:

your provider ID number; � the last four digits of your tax ID number � or your national provider identifier (NPI);member’s ID number; �

member’s name and date of birth; �date of service; �setting, procedure code; �diagnosis code; � the name, address, and telephone number of both the �servicing provider/facility and the requesting provider.

A tutorial for using the new IVR system will be included in a future edition of Partners in Health Update. *For behavioral health services, providers should still call the number on the member’s ID card under Mental Health/Substance Abuse.

speCIalty pharmaCy

Important changes about self-injectable drug coverage coming January 1, 2010*In an effort to provide better access to self-injectable drugs with greater value for our commercial HMO, POS, and PPO members, we are changing the way we cover self-injectable drugs, effective January 1, 2010. These changes, in tandem with a series of billing code changes described in this section, are part of our evolving overall approach to managing specialty pharmaceutical benefits. We will be communicating a series of changes over the next two years, all aimed at ensuring that members are getting the right drug in the right setting at the right time for the best value.

Members will be notified of the changes to self-injectable drug coverage beginning in January 2009 and may have questions for you. Below is a brief description of the scheduled changes to help you answer questions that your patients may have.

Starting on January 1, 2010, we will no longer provide benefits for most self-injectable drugs under our medical benefits program. However, if an HMO, POS, or PPO member has AmeriHealth pharmacy coverage, his or her self-injectable drugs will continue to be covered under his or her pharmacy benefits in 2010. If members have

prescription coverage from another carrier, they should check to see whether their plan includes coverage for self-injectables.

The self-injectable drugs that will no longer be covered under our medical benefits programs are those that patients typically administer themselves and do not require physician monitoring.

We will continue to cover those self-injectables under the medical benefits program at the appropriate cost-sharing levels that:

cannot be administered without medical supervision; �

are mandated by law to be covered (e.g., insulin); �

are required for emergency treatment under the �medical benefits program, such as self-injectable drugs that effectively counteract allergic reactions (e.g., EpiPen®).

If you have any questions about these impending changes, please call 1-800-275-2583, prompt 2 for Provider Services.

*These changes are pending approval for New Jersey and Delaware members.

www.amerihealth.com/providersJanuary 200911

speCIalty pharmaCy

Valid NDC required on claims submitted for drugs (e.g., J codes and other drug codes)As part of our overall approach to managing specialty pharmaceutical benefits, we will be communicating to you over the next two years about some changes that will help members to get the right drug in the right setting at the right time for the best value. We want to share with you some changes to the National Drug Code (NDC) submission.

Please be advised that a new edit is now in place to validate the NDC on any paper or electronic claims submitted with an unlisted and non-specific drug code. By requesting this detailed drug billing information, we can provide greater transparency for our members and providers. Please review the billing requirements below for your applicable provider type. Certain claims for unlisted and non-specific drug codes that are not accompanied by an NDC in the correct format and location as described on the following page will not be processed and will be returned to you for correction prior to processing.

For professional providers: Effective January 1, 2009, claims for all unlisted and non-specific drug codes (CPT® or HCPCS) require submission of an NDC in the correct format and location, as described on the following page. If the NDC is not submitted in the correct format or is missing, the claim will not be processed and will be returned to you for correction prior to processing. The complete list of unlisted and non-specific codes that require the submission of an NDC is below.

For home infusion providers: Effective January 1, 2009, all drug claims (not just the unlisted and non-specific CPT or HCPCS codes in the table below) require the submission of an accompanying 11-digit NDC. This includes claims for hemophilia factor products that are currently submitted with specific J codes.

For institutional providers: Tentatively scheduled for mid-first quarter 2009, all claims for outpatient services containing the following pharmacy revenue codes and an unlisted and non-specific (CPT or HCPCS) code will require a valid NDC when submitted: 250-259, 262, 263, 331, 332, 335, 343, 344, and 631-637.

NDC billing informationPlease submit the NDC number using the 5-4-2 format when billing with hyphens (e.g., 12345-1234-12). NDC numbers without hyphens (e.g., 12345678911) will also be accepted. Please do not include spaces, decimals, or other characters in the 11-digit string, or the claim will be returned for correction prior to processing.

continued on page 12

Unlisted codes that will require submission of an NDC*

Code Description

90399 Unlisted immune globulin

90749 Unlisted vaccine/toxoid

A4641 Radiopharmaceutical, diagnostic, not otherwise classified

A9150 Nonprescription drug

A9152 Single vitamin/mineral/trace element, oral, per dose, not otherwise specified

A9579 Injection, gadolinium based magnetic resonance contrast agent, not otherwise specified, per ml

A9698 Nonradioactive contrast imaging material, not otherwise classified, per study

A9699 Radiopharmaceutical, therapeutic, not otherwise classified

A9700 Supply of injectable contrast material for use in echocardiography, per study

C2698 Brachytherapy source, stranded, not otherwise specified, per source

C2699 Brachytherapy source, nonstranded, not otherwise specified, per source

C9399 Unclassified drugs or biologicals

J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg

www.amerihealth.com/providersJanuary 200912

speCIalty pharmaCy

N400026064871

Code Description

J3490 Unclassified drugs

J3530 Nasal vaccine inhalation

J3535 Drug administered through a metered dose inhaler

J3590 Unclassified biologics

J7199 Hemophilia clotting factor, not otherwise classified

J7599 Immunosuppressive drug, NOC

J7699 NOC drugs, inhalation solution administered through DME

J7799 NOC drugs, other than inhalation drugs, administered through DME

J8498 Antiemetic drug, rectal/suppository, not otherwise specified

J8499 Prescription drug, oral, nonchemotherapeutic, NOS

J8597 Antiemetic drug, oral, not otherwise specified

J8999 Prescription drug, oral, nonchemotherapeutic, NOS

J9999 NOC, antineoplastic drug

Q3001 Radioelements for brachytherapy, any type, each

Q4082 Drug or biological, not otherwise classified, Part B drug competitive acquisition program (CAP)

Q4096 Injection, von Willebrand factor complex human, ristocetin cofactor (not otherwise specified), per I.U. VWF:RCO

S5000 Prescription drug, generic

S5001 Prescription drug, brand name*These codes are subject to change pending routine updates.

Listing these codes on the table does not imply that a separate payment will be made for the code; that all current and future coding edits apply, and that these codes should only be reported when there is not a more specific code.

Please submit an NDC in the following fields: Electronic professional claims: 837P Loop 2410/Data Element LIN02 = N4 qualifier and Data Element LIN03 = NDC �

Example: LIN**N4*00093723106~ −

Paper professional claims: field 24A in the shaded area above the date of service. �

Report the N4 qualifier in the first two positions left-justified followed by the 11-digit NDC with no spaces in between.

Example: −

Electronic institutional claims: 837I Loop 2410/Data Element LIN02 = N4 qualifier and Data Element LIN03 = NDC �Example: LIN**N4*00093723106~ −

Paper institutional claims: box 43 (revenue code description) �

Report the N4 qualifier in the first two positions left-justified followed by the 11-digit NDC with no spaces in between.

Example: N400093723106 −

For information on claims submission resolution, please refer to the Claims Preprocessing Edits Claims Resolution Document at www.amerihealth.com/providers/self_service_tools/edi/forms.html.

If you have questions, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.

Valid NDC required on claims submitted for drugs (continued)

www.amerihealth.com/providersJanuary 200913

Mandated provider claim appeals process (NJ only)

In the November 2006 edition of Partners in Health Update we published an article on the mandated Provider Claim Appeal Form. The New Jersey Senate Bill (SB) 2824, known as the Health Claims Authorization, Processing, and Payment Act (HCAPPA) requires submission of the form for all AmeriHealth New Jersey provider claim appeals.

First level provider appealAs a reminder, and in accordance with the provisions of HCAPPA, a health care provider may initiate a first level provider appeal. The appeal must be initiated on or before the 90th calendar day following receipt of our claims determination using the Health Care Provider Application to Appeal a Claims Determination form as specified by the New Jersey Department of Banking and Insurance (DOBI).

Along with the DOBI form, the provider should submit any additional relevant information in support of the appeal. A copy of this form is available on our website at www.amerihealth.com/pdfs/providers/forms/appeals_claim_form.pdf. Please send the claim form and any supporting documentation to:

AmeriHealth New Jersey Provider Claim Appeals UnitP.O. Box 7218Philadelphia, PA 19101

Appeal arbitrationShould the provider dispute the appeal determination made by the carrier, the provider may initiate an arbitration request through the New Jersey Program for Independent Claims Payment Arbitration (PICPA) by completing the PICPA form within 90 calendar days of receipt of the appeals decision. Claims are eligible for arbitration only if the original appeal was filed on the Health Care Provider Application to Appeal a Claims Determination form.

No dispute will be accepted for arbitration unless the payment amount in dispute is $1,000 or more; however a health care provider may aggregate his own disputed claim amounts for the purposes of meeting the requisite threshold requirements. No dispute pertaining to medical necessity that is eligible to be submitted to the Independent Health Care Appeals Program shall be subject to arbitration. For more information on the PICPA, please visit https://njpicpa.maximus.com/.

For more information regarding New Jersey provider appeals and arbitration processes, please refer to the State of New Jersey DOBI website at www.state.nj.us/dobi/chap352/352implementnotice.html.

The Provider Claims Appeal process has been modified in accordance with the Health Claims Authorization, Processing, and Payment Act. Professional providers should refer to their AmeriHealth Provider Manual for Participating Professional Providers CD; Facility and Ancillary providers should refer to the upcoming Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers.

If you have additional questions, please contact Customer Service at 1-800-275-2583, prompt 2 for Provider Services or your Network Coordinator or Hospital/Ancillary Services Coordinator.

appeals

www.amerihealth.com/providersJanuary 200914

SMART® Registry release for January 2009

The next release of the SMART Registry will be mailed to our providers this month. The SMART Registry provides information on ConnectionsSM Health Management Program-eligible members with asthma, diabetes, heart failure, coronary heart disease (CHD), and chronic obstructive pulmonary disease (COPD).

Four new template letters have been added to this SMART Registry release. Providers can use these letters for members who have heart failure, hypertension, CHD, and COPD. These letters are in addition to the asthma and diabetes template letters that were previously available. Providers can fill out and send the letters to members to remind them about needed follow-up care, such as tests, medication reviews, and office visits. A Microsoft Excel® file of the names and addresses for all members on the Registry is also included to assist providers in sending out the template letters.

As with the June 2008 release, all practices with more than 11 members with a chronic condition who are eligible for the Connections Program will receive their SMART Registry on CD. If you have any questions about the SMART Registry CD, please contact a Provider Service Specialist (PSS) by calling the Connections Program Provider Support Line at 1-866-866-4694. A PSS can work with you and your clinical office staff to sort the CD to provide the most important information for you.

PSSs can also meet with you and your staff to review the SMART Registry reports and to help with making referrals to the Connections Health Management Program.

To speak with a PSS about the SMART Registry or any other aspect of the Connections Program, call the Provider Support Line at 1-866-866-4694.

SMART® is a registered trademark of Health Dialog Services Corporation, an independent company. Used with permission.

Excel® is a registered trademark of Microsoft Corporation in the U.S. and/or other countries.

preventIve health

ConnectionsSM Health Management Programs:supporting our members, your patients

Call the Provider Support Line at 1-866-866-4694 to refer a member for Health Coaching with any of the following conditions:

ConneCtionssM

HealtH

ManageMent

PrograM

n asthma

n diabetes

n chronic obstructive pulmonary disease (COPD)

n �coronary heart disease (CHD)

n migraine

n heart failure

n hypertension

n gastroesophageal reflux disease (GERD)

n peptic ulcer disease (PUD)

Call our Care Management and Coordination department at 1-800-313-8628 to refer a member with end-stage renal disease on outpatient dialysis.

Connections Health Management Programs information, handouts, and brochures are available by visiting www.amerihealth.com/providers/resources/connections.html.

ConneCtionssM

aCCordantCaretM

PrograM

Call 1-866-398-8761 to refer a member with any of the following diseases the Connections AccordantCare Program:n seizure disorders

n rheumatoid arthritis

n multiple sclerosis

n Crohn’s disease

n Parkinson’s disease

n systemic lupus erythematosus (SLE)

n myasthenia gravis

n sickle cell disease

n cystic fibrosis

n hemophilia

n scleroderma

n polymyositis

n dermatomyositis

n chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)

n amyotrophic lateral sclerosis (ALS)

n Gaucher disease

Health Coaches provide disease management and decision support for numerous health-related issues, such as depression, chronic pain, cancer, and weight loss surgery.

View our online provider directories on www.amerihealth.com

Important resourCes

This is not a statement of benefits. Benefits may vary based on state requirements, Benefit Program (HMO, PPO, Indemnity, etc.), and/or employer groups. Providers should call Provider Services, listed at right, for the member’s applicable benefit information. Members should be instructed to call the Customer Service telephone number listed on their ID card.

Not all benefit plans use Magellan Behavioral Health, Inc. to administer behavioral health benefits. Please check the back of the member’s ID card for the telephone number to contact for behavioral health services, if applicable.

The third-party websites 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.

CPT® (Current Procedural Terminology) copyright 2007 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT.

NaviMedix® and NaviNet® are a registered trademarks of NaviMedix, Inc.

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

Partners in Health Update is an independent publication and is not affiliated with, nor has it been authorized, sponsored, or otherwise approved by Microsoft Corporation.

Partners in Health 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:

John ShermerManaging Editor

Charleen BaseliceProduction Coordinator

Provider CommunicationsAmeriHealth1901 Market Street 35th FloorPhiladelphia, PA 19103

providercommunications @amerihealth.com

Visit our website: www.amerihealth.com/providers/communications 01/09

American Imaging Management (AIM) (Call for CT, MRI/MRA, PET, and Nuclear Cardiology) 1-800-859-5288

CARE MANAGEMENT AND COORDINATION Case Management 1-800-313-8628

Baby FootSteps® 1-800-598-BABY (2229)

AmeriHealth Healthy LifestylesSM Keys to Wellness (PA and DE only) 1-800-313-8628

CONNECTIONSSM HEALTH MANAGEMENT PROGRAMS ConnectionsSM Health Management Program Provider Support Line 1-866-866-4694

ConnectionsSM AccordantCareTM Program 1-866-398-8761

CORPORATE AND FINANCIAL INVESTIGATIONS DEPARTMENT Anti-Fraud and Corporate Compliance Hotline

1-866-282-2707www.amerihealth.com/anti-fraud

CREDENTIALING Credentialing Hotline Credentialing Violation Hotline

www.amerihealth.com/credentials215-988-6534215-988-1413

Credentialing and Re-credentialing inquiries (NJ only) 1-866-227-2186

CuSTOMER SERVICE (Policies/Procedures/Claims) HMO and PPO

1-800-275-2583, prompt 2 for Provider Services

eBuSINESS Help Desk 215-241-2305

FutureScripts®

Prescription Drug Authorization Toll Free Fax

1-888-678-70121-888-671-5285

Direct Ship Injectable Fax

1-888-678-7012215-761-9165

Blood Glucose Meter Hotline 1-888-678-7012

FutureScripts® Secure Medicare Part D Formulary updates

1-888-678-7015

www.amerihealth65.com

HEALTH RESOuRCE CENTER AmeriHealth Healthy LifestylesSM 1-800-275-2583

Precertification 1-800-275-2583

NAVINET® PORTAL REGISTRATION

PROVIDER MEDICAL POLICY WEB PAGE www.amerihealth.com/medpolicy

PROVIDER PHARMACY WEB PAGE www.amerihealth.com/provider_rx

PROVIDER SuPPLY LINE 1-800-858-4728

www.amerihealth.com/providers/navinet/index.html

AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • QCC Insurance Company d/b/a AmeriHealth Insurance Company

OMB Approval 0938-0829

NOTICE OF DENIAL OF MEDICAL COVERAGE ________________________________________________________________Date: Member ID Number:

Beneficiary’s name:________________________________________________________________

We have denied coverage of the following medical services or items that you or your physician requested: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________We denied this request because:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What If I Don’t Agree With This Decision?

You have the right to appeal. To exercise it, file your appeal in writing within 60 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline.

Who May File An Appeal?

You or someone you name to act for you (your representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others also already may be authorized under State law to act for you.

You can call us at: (___) ________ to learn how to name your representative.If you have a hearing or speech impairment, please call us at TTY (___) ______.

If you want someone to act for you, you and your representative must sign, date, and send us a statement naming that person to act for you.

Form No. CMS-10003 Exp. Date 8/31/2010

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0829. The time required to complete this information collection is estimated to average 6.3 to 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.