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APIPA
Provider Newsletter
An important message to health care professionals and facilities
Summer 2010
UTILIZATION REVIEW
AmeriChoice staff performs concurrent review on inpatient stays in
acute, rehabilitation and skilled nursing facilities, as well as prior
authorization reviews of selected services. A listing of services
requiring prior authorization is available in the Provider Manual. A
physician reviews all cases in which the care does not appear to
meet guidelines. Decisions regarding coverage are based on the
appropriateness of care and service and existence of coverage.
AmeriChoice does not reward physicians for issuing denials of
coverage. The decisions are in no way influenced by financial
Articles of Importance
to Read:
UTILIZATION REVIEW . . . . . . . . . . . . 1
CARE MANAGEMENT AND
DISEASE MANAGEMENT. . . . . . . . . 2
MEDICAL RECORD CRITERIA. . . . . . 2
PHARMACY UPDATES . . . . . . . . . . . 3
Is Your Patient Eligible for
Children’s Rehabilitative
Services (CRS)? . . . . . . . . . . . . . . . . . 3
incentives of any kind. The treating physician has the right to request
a peer-to-peer review with the reviewing physician and to request a
copy of the criteria used in the review. The denial letter contains
APIPA members can also choose
certified nurse midwives for
Obstetrical care. . . . . . . . . . . . . . . . . 4
information on how to request materials and how to contact the
reviewer. Members and practitioners also have the right to appeal
What is EDI? . . . . . . . . . . . . . . . . . . . . 4
denial decisions. Information on requesting an appeal is included in
Dual-Eligible Special Needs
Plans Important Information
for Providers . . . . . . . . . . . . . . . . . . . . 6
the denial letter. Appeals are reviewed by a physician who was not
involved in the initial denial decision and who is of the same or
similar specialty as the requesting physician. The appeal request
must be submitted within 90 days of the denial.
Requests should be mailed to:
AmeriChoice Appeals
P.O. Box 31365
Salt Lake City, UT 84131
Urgent appeals may be requested by calling: 1-866-331-2243.
The following new policies will
be implemented by APIPA . . . . . . . . 7
APIPA THERAPY PRIOR
AUTHORIZATION UP DATE 5/2010 . . . . . . . . . . . . . . . . . . . . . . . . . . 7
HPV SHOTS FOR FEMALES
AND MALES . . . . . . . . . . . . . . . . . . . . 8
FOCUS ON: ATRIAL
FIBRILLATION . . . . . . . . . . . . . . . . . . . 8
MEMO FROM JANET BREWER,
GOVERNOR . . . . . . . . . . . . . . . . . . . . 10
APIPA Provider Newsletter
CARE MANAGEMENT AND
DISEASE MANAGEMENT
The AmeriChoice Personal Care Model® is a
holistic approach to care for members with
complex needs, especially for those with
chronic conditions. The goal is to keep our
members in the community with the
resources necessary to maintain the highest
functional status possible.
What can the AmeriChoice Case Manager
provide for your patients?
• Telephonic contact with members and
home visits as needed
• Disease management programs
• Health education and educational materials
• A health assessment with stratification of
diagnosis and severity of condition and
psychosocial needs
• Referral to community resources as needed
Areas of Expertise
• Disease Management programs
– Diabetes
– CHF
– Asthma
– HIV
– COPD
– Sickle cell
• Special Needs Case Management (adults
and children)
• Complex Needs Case Management
• Pediatrics/NICU Case Management
• Emergency Room Utilization Case
Management
• Healthy First Steps Program for pregnant
women (do not have to be high risk to
receive this service)
How to refer
For more information or to make a referral,
call our referral line at 866-331-2243.
• Assistance with medical transportation
• Arrangements for DME and ancillary
services as needed or ordered by the
physician
• Outreach to members to promote
assistance with keeping doctor’s
appointments
• Work with members to identify and address
barriers to seeking health care and to
following their medical treatment plan
of care
MEDICAL RECORD CRITERIA
• All medical records are to be stored
securely.
• Only authorized personnel have access
to records.
• Staff receives periodic training in member
information confidentiality.
• Medical Records are organized and stored
in a manner that allows easy retrieval.
• Medical Records are stored in a secure
manner that allows access by authorized
personnel only.
page 2
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
• Medical Records must include: History &
Physical; Allergies and Adverse Reactions;
Problem List; Medications; Preventive
Services/Screening; Documentation of
clinical findings for each visit.
PHARMACY UPDATES
Just a reminder: Pharmacy Updates are
available at www.americhoice.com. The
pharmacy hotline is 1-866-651-2217.
What Conditions are Covered by APIPACRS?
A complete list of covered conditions can be
found on the Arizona Department of Health
Services web site at:
www.azdhs.gov/phs/ocshcn/crs/crs_policy_az.htm.
Some of the eligible conditions include but
are not limited to:
• Cerebral Palsy,
• Club feet,
Is Your Patient Eligible for
Children’s Rehabilitative
Services (CRS)?
The CRS program has been serving children
with special health care needs since 1929.
CRS provides medical care and support
services to children and youth who have
certain chronic or disabling conditions.
Arizona Physicians IPA-CRS (APIPA-CRS) has
been the administrator of the program since
October 2008.
Who is Eligible for APIPA-CRS Services?
APIPA-CRS does not determine eligibility
based on income. To be eligible for APIPACRS services a child must:
• Have certain medical conditions,
• Be under age 21,
• Be a U.S. citizen or qualified alien, and
• Live in Arizona.
page 3
• Dislocated hips,
• Cleft palate,
• Scoliosis,
• Spina Bifida,
• Cystic Fibrosis,
• Heart conditions due to congenital
anomalies,
• Metabolic disorders,
• Muscle and nerve disorders,
• Neurofibromatosis, and
• Sickle cell anemia
What Services Does APIPA-CRS Cover?
APIPA-CRS provides services that are related
to a patient’s CRS eligible medical condition.
Basic medical care for things such as shots,
colds, the flu, earaches, sprains, etc. are not
covered by the APIPA-CRS program. AHCCCS
or any other insurance will take care of your
patient’s primary health care needs.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
How to Refer a Patient to CRS
It’s simple to refer a child to CRS. All that’s
needed is a simple application and supporting
medical records. To get an application:
• Call APIPA-CRS Provider Services at 1-866275-5776
• Go to our web site at www.myapipacrs.com
to download an application.
• Visit the Office for Children with Special
Health Care Needs web site at
www.azdhs.gov/phs/ocshcn/crs/crs_az.htm
to download an application.
A Referral Guideline document is also
available on our web site. It provides
guidance on the type of medical
documentation required for each eligible
condition.
Completed applications packets can be mailed
or faxed to:
APIPA-CRS
Attn: Eligibility and Enrollment
PO Box 33320
Phoenix, AZ 85067-3320
Fax: 1-866-623-1692
APIPA members can also
choose certified nurse midwives
for Obstetrical care.
APIPA members can be assigned to certified
nurse midwives who are under the
supervision of a contracted obstetrician.
Certified nurse midwives can provide prenatal
care, labor/delivery and postpartum care
within the scope of their practice and will be
required to meet the AHCCCS requirements
and APIPA policy and procedures. The
Credentialing and Re-credentialing Committee
review process monitors nurse midwife
performance according to the same standards
as other APIPA contracted practitioners.
What is EDI?
Electronic Data Interchange allows providers
to submit and receive electronic transactions
from their computer systems.
EDI is the process of using computers to
exchange business documents between
computers. Previously fax machines or
traditional mail was used to exchange
documents. Mailing and faxing are still used
in business, but EDI is a much quicker way to
do the same thing.
EDI is used by a huge number of healthcare
providers. This system has a number of
benefits; cost is one of them. Computer-tocomputer exchange is much less expensive
than traditional methods of claims
submission. Research has shown that it costs
a provider organization $7.00 - $12.00 to
process a paper based claim, where it only
costs $1.50 - $3.00 to process the same claim
electronically.
Advantages of EDI
• Improves accuracy
• Reduces paperwork, costs, and number of
rejections
• Reduces time
• Tracks and monitors of claims
• Decreases payment turnaround time
• Positive environmental impact
page 4
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
What Is EFT or Electronic Funds Transfer
And How Does It Work?
An electronic funds transfer (also known as
EFT) is a system for transferring money from
one bank to another without using paper
money. Its use has become widespread with
the arrival of personal computers, cheap
networks, improved cryptography and the
Internet.
Since it is affected by financial fraud, the
Electronic Funds Transfer act was
implemented. This federal law protects the
consumer in case a problem arises at the
moment of the transaction.
Advantages of ERA
• Reduces accounts receivable errors and
administrative costs
• Provides prompt delivery of Electronic
Remittance Advices to providers, usually
before paper copies arrive
We encourage providers to contact their
electronic vendors and clearinghouses to
learn more about additional options available
such as:
• Manual and automated posting
• Single easy-to-read, printer friendly format
for multiple payers
Advantages of EFT
• EFT is safe, secure, efficient, and more cost
effective than paper claim payments
• Easy access to payer Explanation of
Benefits (EOBs)
• Electronic payments reduce administrative
costs, simplify bookkeeping, and offer
greater security
• Automated coordination of benefit claims
filing
• The funds are available for use as soon as
they are posted to your account
• Payments are private and secure—a
network of computers does the work
Electronic Remittance Advice (ERA)
AmeriChoice offers electronic delivery of
remittance advices. The remittance advice
provides information for the payee regarding
claims in their final status.
The content on the remittance advice meets
HIPAA requirements, containing nationally
recognized HIPAA-compliant remark codes
used by Medicare and other payers like
AmeriChoice.
page 5
• Capability to quickly locate documents for
research and customer service
• Image retrieval, eliminating loss of misfiled
documents
• Support and Staff training
For Additional Information on EDI, please
refer to the Provider Manual posted on
AmeriChoice Online (www.americhoice.com),
our FAQ documentation, or you may contact
AmeriChoice EDI (AmeriChoice) Support
Services directly.
AmeriChoice EDI Support Services
[email protected]
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
Dual-Eligible Special Needs
Plans Important Information for
Providers
Under the Medicare Modernization Act of
2003 (MMA), Congress created a new type of
Medicare Advantage coordinated care plan
focused on individuals with special needs.
Special needs plans (SNPs) were allowed to
focus enrollment to one or more types of
special needs individuals identified by
Congress as: 1) institutionalized; 2) dually
eligible; and/or 3) individuals with severe or
disabling chronic conditions.
The SNP plans maintain and monitor a
network of participating providers including
physicians, hospitals, skilled nursing facilities,
ancillary providers and other health care
providers through which Members obtain
covered services.
Key points about coordination of care for SNP
Members include:
• SNP Members are encouraged to choose a
Primary Care Physician (PCP) to coordinate
their care. If a PCP is not chosen, the
selection will be made for the member.
• The SNP works with contracted PCPs who
manage the health care needs of SNP
members and arrange for medically
necessary covered medical services,
including prior authorizations as necessary.
• PCPs may, at any time, advocate on behalf
of the member without restriction in order
to ensure the best care possible for the
member.
page 6
• To ensure continuity of care, Members are
encouraged to coordinate with their PCP
before seeking care from a specialist,
except in the case of specified services
(such as women’s routine preventive health
services, routine dental, routine vision, and
behavioral health).
• Contracted providers are required to
coordinate member care within the SNP
provider network. If possible, all SNP
member referrals should be directed to the
SNP contracted providers.
• Referrals outside of the network are
permitted, but only with prior authorization
from the SNP.
Key points related to billing for services for
SNP Members include:
Full-Duals and Qualified Medicare
Beneficiaries (QMBs) are not responsible for
Medicare cost-sharing under Title XIX of the
Social Security Act. You must not charge
these dual eligible members for cost-share or
balance bill them for any part of the unpaid
charges. Rather, you may bill AmeriChoice
and then submit the secondary claim to the
member's Medicaid coverage provider. For
these individuals, the payment from
AmeriChoice as well as any payment received
from the Medicaid coverage provider should
be considered payment in full.
To learn about the full range of benefits and
services for which members are eligible, your
responsibility for cost-sharing (if any), and
your right to reimbursement by both
programs please contact 1-800-445-1638.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
The following new policies will
be implemented by APIPA
“Wrong Surgical and Other Invasive
Procedures”
Continuing the pursuit of enhancing the
quality of care for its members, APIPA has
reviewed the Leapfrog Group’s Never Events
and the Centers for Medicare & Medicaid
Services’ (CMS) Present on Admission and
Wrong Surgical and Other Invasive
Procedures positions. Effective August 1,
2010, APIPA is implementing the “Wrong
Surgical and Other Invasive Procedures”
reimbursement policy that states APIPA will
not reimburse for these wrong surgeries and
their related services rendered by providers
present in the operating room. This
reimbursement policy directs physicians and
hospitals to submit bills for these services
with the appropriate bill type, modifier and/or
diagnosis code that were created to identify
these wrong surgeries. The complete policy
will be posted online by July 15, 2010.
APIPA is not following the CMS approach of
considering these non-covered services but
rather stating these services will not be
reimbursed.
“Once in a Lifetime Procedure”
Effective August 15, 2010 APIPA will be
adopting a new policy which describes the
appropriate billing guidelines for reporting
those procedures which by nature of the
procedure, can only be performed once in the
patient’s life. The complete policy will be
posted online After August 15. Changes to
the following policy will be implemented for
claims processed after August 15, 2010.
page 7
Anesthesia Policy:
The current anesthesia policy will have the
following modifications:
• Claims with CPT codes 00100-01999 billed
with a 47 modifier will be denied.
• APIPA will be adopting the CCI pair edits
and will retire the current single code
unbundle list
• The definition of “global period” for
anesthesia services will be reduced to be
defined as the same day services only
The complete revised policy will be posted
only after August 15.
APIPA THERAPY PRIOR
AUTHORIZATION UP DATE 5/2010
Requesting prior authorization for therapy on
behalf of a DDD/LTC member:
DDD/LTC members received new ID cards
January 2010. These cards identify a member
who belongs to DDD on the lower left hand
corner of the ID card. You may also verify a
member belongs to DDD/LTC (long term care)
by checking eligibility on line via AHCCCS
web site.
If you have a patient that belongs to
DDD/LTC and is in need of therapy:
• Please check with the patient first that they
are not receiving therapy services with DDD
or on a wait list for services. Your patient
should be able to provide you with their
DDD support coordinator contact
information. If you need to reach a support
coordinator you may contact DDD at 602238-9028 ext 6029.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
• Please check with the patient first that the
prescription written for therapy is not a
request for updating the member’s DDD
medical records. If a request for an
updated script for record keeping purposes,
please hand it to the patient to hand carry
to their DDD support coordinator or fax to
the support coordinator from your office.
• If the request for therapy is rehabilitative in
nature, then this request may occur
following surgery or after a trauma that has
decreased the functioning of an individual.
Rehabilitative therapies are not designed to
build a skill or functioning level that has not
been previously presented in an individual,
unless the intervention was designed to
increase function, as with the release of
contractures. This is a service covered
under patients’ APIPA (AHCCCS benefits).
Please direct these requests to APIPA PA
department at 866-604-3267.
• If the request is habilitative in nature, then
this is a benefit covered under patients’
DDD benefit. Please direct these requests
to the patients’ DDD support coordinator
for approval though DDD. Definition:
habilitative therapy assists patients in
acquiring, retaining and/or improving the
following, necessary to reside successfully
in the community: self help, socialization,
adaptive skills or strength.
page 8
HPV SHOTS FOR FEMALES AND
MALES
According to the ACIP recommendations, the
CDC has included coverage of HPV for males
ages 11-18 years, (9-10 years if at high risk).
During the April AHCCCS Policy Committee
Meeting, AHCCCS approved adding HPV
vaccine for males through the VFC Program.
As with all VFC covered
immunizations/vaccinations, AHCCCS
Contractors are only responsible for the cost
of administration. At the same policy
meeting, AHCCCS modified the age
parameters for HPV vaccine coverage to
EPSDT age range only, or up to age 21 years.
Coverage of HPV vaccine for females 21-26
years will no longer be a covered AHCCCS
service beginning on 7/1/10.
FOCUS ON: ATRIAL FIBRILLATION
“Atrial fibrillation is the most common
arrhythmia in clinical practice, accounting for
approximately one-third of hospitalizations for
cardiac rhythm disturbances.”1 As with other
chronic conditions, atrial fibrillation and other
arrhythmias must be assessed, documented
and accurately coded each calendar year.
Because patients with atrial fibrillation often
have other chronic conditions (e.g. heart
failure), these, too, should be assessed,
documented and coded as well. Since many
patients with atrial fibrillation are on chronic
warfarin therapy, the appropriate “V” code
should be used in addition to the code for
atrial fibrillation.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
Documentation Tips
Coding Pearls
Documentation for heart arrhythmias that
clearly identifies the condition promotes
better quality of care. Nonspecific
documentation will always lead to nonspecific
medical coding.
Consider the following codes in identifying
the arrhythmia:
427.0 Paroxysmal supraventricular
tachycardia
427.1 Paroxysmal ventricular tachycardia
427.2 Paroxysmal tachycardia, unspecified
427.31 Atrial fibrillation
427.32 Atrial flutter
427.41 Ventricular fibrillation
427.42 Ventricular flutter
427.5 Cardiac arrest
427.60 Premature beats, unspecified
427.61 Supraventricular premature beats
427.69 Premature beats, other
427.81 Sinoatrial node dysfunction
Sinus bradycardia: persistent or severe
Syndrome: sick sinus or tachycardiabradycardia
DEF: Complex cardiac arrhythmia; appears
as severe sinus bradycardia, sinus
bradycardia with tachycardia, or sinus
bradycardia with atrioventricular block2
427.89 Other specified cardiac dysrhythmias
Rhythm disorder: coronary sinus, ectopic or
nodal
Wandering (atrial) pacemaker
427.9 Cardiac dysrhythmia, unspecified
Always document and code other diagnoses
that were assessed at the time of the patient’s
visit, for example:
Assessment: Patient with chronic atrial
fibrillation, rate controlled with beta blocker,
with stable congestive heart failure. Remains
on chronic warfarin, INR therapeutic.
427.31 Atrial fibrillation
428.0 Congestive heart failure, unspecified
V58.61 Long-term (current) use of
anticoagulants
Patients who were converted to normal sinus
rhythm (NSR) from atrial fibrillation and
remain on medication to maintain NSR
should still be coded as atrial fibrillation.
Assessment: Successful cardioversion of atrial
fibrillation one month ago, stable on
amiodarone and remains in normal sinus
rhythm.
427.31 Atrial fibrillation
Always…
• Assess and document cardiac arrhythmias
at least annually.
• Code to the highest level of specificity;
avoid use of “unspecified” codes.
• Code other chronic conditions evaluated at
time of visit, e.g. heart failure.
These codes are to be used for easy
reference; however, the ICD-9-CM code book
is the authoritative reference for correct
coding guidelines. The information presented
herein is for information purposes only.
Ingenix, Inc. does not warrant or represent
that the information contained herein is
accurate or free from defects. © 2010 Ingenix,
All Rights Reserved • Codes Valid 10/01/09 to
9/30/10
1 ACC/AHA/ESC “2006 Guidelines for the Management of Patients
with Atrial Fibrillation.” American College of Cardiology
<www.acc.org>
2 Ingenix ICD-9-CM 2010 Expert for Physicians Vol 1 & 2
page 9
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
MEMO FROM JANET BREWER,
GOVERNOR
DATE:
April, 2010
TO:
Holders of AHCCCS Contractor
Operations Manual
FROM:
Stewart McKenzie,
Administrative Services
Officer III
Division of Health Care
Management, AHCCCS
SUBJECT:
AHCCCS Contractor
Operations Manual (ACOM)
Update 2010-04
This memo describes any changes and/or
additions to the ACOM Manual for the month
of April, 2010. In addition, the Grievance
System Reporting Guide and Attachments has
been updated as described below.
Chapter 100 – Administration, Policy 101,
Marketing, Outreach and Retention
Section IV (Procedure), subsection A.3 (School
Based Events) has been deleted and the
remainder of Subsection A has been
renumbered. School based events and
KidsCare Marketing have been added to the
list of Temporary Restrictions in Subsection
IV. D (Temporary Restrictions). Language for
this paragraph has also been updated.
Chapter 200 – Claims, Policy 201, Medicare
Cost Sharing for Members in Medicare FFS
Section III, B, Limits on Cost Sharing, has had
an exception added to state, “The exception
to these limits on payments as noted above is
that the Contractor shall pay 100% of the
member copayment amount for any Medicare
page 10
Part A Skilled Nursing Facility (SNF) days (21
through 100) even if the Contractor has a
Medicaid Nursing Facility rate less than the
amount paid by Medicare for a Part A SNF
day.”
Chapter 200 – Claims, Policy 202,
Medicare Cost Sharing for Members in
Medicare HMO
Section III, C, Limits on Cost Sharing, has had
an exception added to state, “The exception
to these limits on payments as noted above is
that the Contractor shall pay 100% of the
member copayment amount for any Medicare
Part A Skilled Nursing Facility (SNF) days (21
through 100) even if the Contractor has a
Medicaid Nursing Facility rate less than the
amount paid by Medicare for a Part A
SNF day.”
Chapter 400 – Operations, Policy 424,
Verification of Receipt of Paid Services
A technical correction has been made to this
chapter. One due date for the Quarterly
Verification of Services Audit Report has been
corrected from August 15th to July 15th. This
does not reflect any change in policy.
Chapter 400 – Operations, Policy 425,
Social Networking
A definition of “broadcast” has been added to
Section III (Definitions). A reference to
broadcast has been added to Subsection IV. C
(User Requirements) in item 7. “All static,
distributed or broadcast content must be
generated …”
Grievance System Reporting Guide and
Attachments
Although the revised Grievance System
Reporting Guide (Version 3.2) effective April,
2010 and attachments is not part of the
AHCCCS Contractor Operations Manual
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
(ACOM), this notice is being sent to ensure
communication of this revision. The April
2010 version replaces the previous version of
the Guide (version 3.1) and is posted on the
AHCCCS website.
Grievance System Reporting Guide
Summary of Changes
1. The definition of "claim dispute" has been
revised and clarified.
2. All reports "must" be completed using the
guidelines.
3. A reference to ACOM policy 414 (Content
of Notices of Action) has been added to
section A.2 of the Authorization Request
and Appeal Report instructions.
4. Categorical sub-classifications have been
clarified in the Enrollee Grievance Report.
5. Attachment G, Access to Care, is new.
Individuals with questions related to this
policy should contact Alan Schafer at
417-4614 or Rodd Mas at 417-4072
Newsletter articles provide general guidance.
Always consult your contract or call the
Provider Service Center (800-445-1638) with
any questions.
3141 North Third Avenue
Phoenix, AZ 85013
The APIPA Provider Newsletter is a periodic publication for physicians and other health care
professionals and facilities in the APIPA network.
M45450 8/10