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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