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PARTICIPATING PROVIDER ORIENTATION. AmeriHealth VIP Care and AmeriHealth VIP Select This training program is designed to familiarize Providers with AmeriHealth.

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Presentation on theme: "PARTICIPATING PROVIDER ORIENTATION. AmeriHealth VIP Care and AmeriHealth VIP Select This training program is designed to familiarize Providers with AmeriHealth."— Presentation transcript:

1 PARTICIPATING PROVIDER ORIENTATION

2 AmeriHealth VIP Care and AmeriHealth VIP Select This training program is designed to familiarize Providers with AmeriHealth VIP Care and AmeriHealth VIP Select. At the conclusion of the training, providers will be familiar with the AmeriHealth VIP Care and AmeriHealth VIP Select’s Model of Care, the role of the Provider in the Model of Care and the AmeriHealth VIP Care and AmeriHealth VIP Select’s resources available to the Provider and Member for both AmeriHealth VIP Care and AmeriHealth VIP Select. AmeriHealth VIP Care is a Medicare Advantage Dual Eligible Special Needs Health Maintenance Organization. (D-SNP/HMO) AmeriHealth VIP Select is a Medicare Advantage Prescription Drug Health Maintenance Organization. (MAPD/HMO) 2

3 3 AmeriHealth VIP Care and AmeriHealth VIP Select are members of the AmeriHealth Caritas Family of Companies - the industry leader in managing medically complex members. We are expanding our membership to continue our vision and mission to provide healthcare services to the underserved. AmeriHealth VIP Care enables us to offer our existing and eligible chronically ill Medicaid members a seamless transition to a Medicare Advantage Special Needs Plan. AmeriHealth VIP Select enables us to offer this same level of service to the traditional Medicare member. Who We Are

4 Why AmeriHealth VIP Care and AmeriHealth VIP Select? As a member of AmeriHealth Caritas, AmeriHealth VIP Care and AmeriHealth VIP Select are uniquely qualified to provide these populations with the coordinated care they deserve. AmeriHealth Caritas – care is the heart of our work: Nearly 5 Million Covered Lives 3,000+ Employees NCQA-Accredited plans 4

5 Why AmeriHealth VIP Care and AmeriHealth VIP Select? AmeriHealth VIP Care and AmeriHealth VIP Select are well equipped to provide high-level customer service to members and providers. AmeriHealth’s corporate systems and centers currently: Handle more than 2.25 million member and provider calls annually in our 24/7 call centers. Process an average of 2.1 million claims each month. Receive more than 87 percent of provider claims electronically with automatic adjudication rates of more than 81 percent. 5

6 Why AmeriHealth VIP Care and AmeriHealth VIP Select? AmeriHealth Caritas Pennsylvania (Harrisburg Area) Excellent Accreditation Keystone First (Philadelphia Area) Excellent Accreditation MDwise Hoosier Alliance (Indiana) Excellent Accreditation Select Health (South Carolina) Excellent Accreditation Based upon NCQA Health Insurance Plan Rankings , issued September 20, The success of AmeriHealth Caritas’ mission-driven programs is evidenced by the national recognition and awards received. All established AmeriHealth Caritas Medicaid plans currently rank in the top 19th percentile of Medicaid health plans: 6

7 AmeriHealth VIP Care and AmeriHealth District of Columbia AmeriHealth Caritas is focused on extending the services that we provide under the AmeriHealth District of Columbia Medicaid Plan to members who have become eligible for Medicare due to age or disability. 7

8 8 We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. Mission Statement

9

10 AmeriHealth VIP Care (D-SNP) Plan Overview AmeriHealth VIP Care Overview  AmeriHealth VIP Care is contracted to provide Medicare Hospital (Part A), Medical (Part B) services, and Prescription Drug Coverage (Part D) services in the District of Columbia. Members must live in one of the eight wards in the District of Columbia to join AmeriHealth VIP Care. AmeriHealth VIP Care Enrollment Will accept only those beneficiaries with dual Medicaid/Medicare eligibility. Members can enroll or change plans at any time. Members can enroll by calling member services at

11 AmeriHealth VIP Care (D-SNP) – Dual Eligible Special Needs Plan Our Members  Reside in one of the eight wards in the District of Columbia.  Have or will soon have Medicare Parts A and B.  Do not have end-stage renal disease.  Receive medical assistance benefits through the District of Columbia Medicaid fee-for-service system. 11

12 Summary of AmeriHealth VIP Care’s Benefit Package Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Hospice – Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Kidney Disease and Condition Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network Catastrophic Prescriptions Outpatient Prescription Drugs Retail Pharmacy Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care 12

13 AmeriHealth VIP Care (D-SNP) Supplemental Benefits – Dental DENTAL SERVICES Preventative Dental Oral Exams – 1 every 6 months Cleaning – 1 every 6 months Fluoride Treatment – 1 every 6 months Dental x-rays – 1 every year Comprehensive Dental Non-routine services including fillings, simple extractions, minor restorations, dentures and denture repair $500 every two years 13

14 AmeriHealth VIP Care (D-SNP) Supplemental Benefits –Vision VISION SERVICES Up to one supplemental routine Eye Exam every year Up to one pair of eyeglasses or contact lenses every two years $150 coverage limit for supplemental eyewear every two years 14

15 AmeriHealth VIP Care (D-SNP) Supplemental Benefits –Hearing HEARING SERVICES Up to one supplemental routine Hearing Exam every year Up to one fitting evaluation for a hearing aid every three years Up to $1,000 coverage for hearing aids every three years 15

16 Supplemental Benefits –Non-Emergency Transportation Transportation Services Twenty-four (24) one-way trips per year to a AmeriHealth VIP Care approved location Car, shuttle, van services, including non-emergent transportation to doctor visits, preventive services, pharmacies and fitness center Authorization and scheduling rules apply 16

17 Supplemental Benefits – Over the Counter Items Over the Counter (OTC) Typically includes medicines or products that alleviate or treat injuries or illness OTC products are shipped directly to the member No statement from a medical provider required or documentation of a diagnosis to use the benefit Up to $50 every three months No roll-over quarter to quarter 17

18 Supplemental Benefits– Health and Wellness Gym Memberships Available to AmeriHealth VIP Care members Members may choose which gym they would like to belong to from gyms such as the YMCA and other local gyms Members may call member services at (888) to arrange for membership 18

19 Supplemental Benefits– 24/7/365 Nurse Line If members are unable to reach their PCP’s office, registered nurses are available 24/7/365 days to assist members through the Nurse Toll-Free Call Line. AmeriHealth VIP Care Nurse Call Line: (855)

20

21 AmeriHealth VIP Select (MA-PD) Plan Overview AmeriHealth VIP Select Overview  AmeriHealth VIP Select is contracted to provide Medicare Hospital (Part A), Medical (Part B) services, and Prescription Drug Coverage (Part D) services in the District of Columbia. AmeriHealth VIP Select Enrollment Beneficiaries must have Part A and B. Members must live in one if the eight wards in the District of Columbia to join AmeriHealth VIP Select. Members can enroll by calling member services at member services (888)

22 AmeriHealth VIP Select– Medicare Advantage Prescription Drug Plan Our Members  Reside in one of the eight wards in the District of Columbia.  Have or will soon have Medicare Parts A and B.  Do not have end-stage renal disease. 22

23 Summary of AmeriHealth VIP Select’s Benefit Package Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Hospice – Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Kidney Disease and Condition Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network Catastrophic Prescriptions Outpatient Prescription Drugs Retail Pharmacy Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care 23

24 AmeriHealth VIP Select Supplemental Benefits – Dental DENTAL SERVICES Preventative Dental Oral Exams – 1 every 6 months Cleaning – 1 every 6 months Fluoride Treatment – 1 every 6 months Dental x-rays – 1 every year $30 copay for up to 1 supplemental oral exam(s) every six months 24

25 AmeriHealth VIP Select Supplemental Benefits –Vision VISION SERVICES $30 copay for up to one supplemental routine Eye Exam every year $100 towards glasses or contacts every two years 25

26 AmeriHealth VIP Select Supplemental Benefits –Hearing HEARING SERVICES $0 copay for Medicare-covered diagnostic hearing exams Routine services are not a covered benefit 26

27 Supplemental Benefits (continued) – 24/7/365 Nurse Line If members are unable to reach their PCP’s office, registered nurses are available 24/7/365 days to assist members through the Nurse Toll-Free Call Line. AmeriHealth VIP Select Nurse Call Line: (855)

28 28 Member Eligibility

29 Member Rights and Responsibilities Federal law requires that health care providers and facilities recognize member rights. Members have the right to request and receive from their health care provider, a complete copy of the Patient’s Bill of Rights and Responsibilities. Providers may refer to the Provider Manual for a detailed listing of the Member’s Rights and Responsibilities. 29

30 Member Welcome Packet AmeriHealth VIP Care and AmeriHealth VIP Select Member welcome packets includes: Cover (Welcome) Letter Provider & Pharmacy Directory The AmeriHealth VIP Care and AmeriHealth VIP Select’s Formulary Evidence Of Coverage (EOC) document Health Risk Assessment (HRA) and return envelope Multi-Language Insert Notice of Privacy Practices Member grievance process Member materials, including a summary of benefits compared to Original Medicare and complete evidence of coverage information, are accessible via our website at www. amerihealthvipdc.com or AmeriHealth VIP Care member services at or AmeriHealth VIP Select member services at www. amerihealthvipdc.com 30

31 Member PCP Selection Members may select a new PCP at any point in time by calling AmeriHealth VIP Care member services at or AmeriHealth VIP Select member services at An updated card will be sent to the member each time there is a change in eligibility or PCP. Because a member may present with a card with old information, AmeriHealth VIP Care and AmeriHealth VIP Select encourages providers to validate member eligibility at each visit. 31

32 Member Eligibility Providers are responsible for verification of member’s eligibility status prior to the delivery of services. Providers may verify eligibility by: Utilizing the monthly member panel roster NaviNet Provider Services for AmeriHealth VIP Care Provider Services for AmeriHealth VIP Select

33 NaviNet What is NaviNet? –A FREE web-based solution for providers and health plans to share critical administrative, financial and clinical data. –America’s largest real-time healthcare communications network, securely linking providers nationwide through a single website. Provider portal address: –https://connect.NaviNet.nethttps://connect.NaviNet.net Informational website –www.NaviNet.netwww.NaviNet.net –NaviNet Web Portal: Phone: (888) www.navinet.net Must be accessed via Internet Explorer v. 7.0 or above –Older versions of IE may not work appropriately –Not accessible via Firefox, Safari or Google Chrome 33

34 NaviNet (continued) NaviNet Functions: View Member Eligibility Member Rosters View Third Party Liability Information (TPL) Claims Status & Updates Prior Authorization HEDIS Performance On-Line Remittance Advice Care Plans Clinical Summary Referrals Care Gaps 34

35 Potential NaviNet Issues Providers who do not show AmeriHealth VIP Care and AmeriHealth VIP Select as an option on the Plan Central page should contact NaviNet to request access. This can occur in two ways. 1.Click on My Account at the top of the NaviNet page Support Cases will be located on the left side of the screen Providers may Open a Case or View a Case here. 2.Send an to NaviNet Support at All Support Cases or requests submitted via should include: –Tax identification Number (TIN) –NaviNet user contact name and phone number –Group and provider NPI’s to be added or terminated –Transaction access request (Eligibility, Referrals, Prior Authorization Management, etc.) 35

36 Accessing Member Eligibility via NaviNet On the AmeriHealth VIP Care and AmeriHealth VIP Select landing page, NaviNet will provide alerts if there are issues with search functions or availability. Providers may also call Provider Services for AmeriHealth VIP Care or Provider Services for AmeriHealth VIP Select to verify eligibility. 36

37 Member Eligibility via NaviNet 37

38 Monthly Panel Roster Provider panel rosters will be available on a monthly basis to provide PCP offices with a listing of AmeriHealth VIP Care and AmeriHealth VIP Select members who have chosen their practice. Member information on the panel roster will include: The member’s name, address and telephone number Date of birth and age Gender Effective date with AmeriHealth VIP Care or AmeriHealth Select Plan AmeriHealth VIP Care and AmeriHealth VIP Select Medicare Identification number State Medicaid Identification Number (if applicable) Primary Language spoken Medicare Plan Type (D-SNP-HMO or MAPD HMO) 38

39 AmeriHealth VIP Care Member Panel Roster 39

40 AmeriHealth VIP Care and AmeriHealth VIP Select– A Medicare Replacement For AmeriHealth VIP Care and AmeriHealth VIP Select members, AmeriHealth VIP Care or AmeriHealth VIP Select should be entered into the provider’s billing system in the place of Medicare Fee for Service. If a provider has Medicare or another Medicare Advantage plan loaded in their patient management system for an AmeriHealth VIP Care or AmeriHealth VIP Select member, AmeriHealth VIP Care or AmeriHealth VIP Select will replace this plan. The AmeriHealth VIP Care member will have District of Columbia Medicaid secondary to AmeriHealth VIP Care, even if the member previously enrolled in AmeriHealth District of Columbia. 40

41 Provider Participation 41

42 AmeriHealth VIP Care and AmeriHealth VIP Select Medicare Provider Eligibility Health care providers are selected to participate in the AmeriHealth VIP Care and AmeriHealth VIP Select Network based on an assessment and determination of the network's needs. Providers must be enrolled with the Medicare program in order to be credentialed with AmeriHealth VIP Care and AmeriHealth VIP Select. 42

43 Provider Credentialing AmeriHealth VIP Care and AmeriHealth VIP Select is responsible for the credentialing and re-credentialing of its provider network. Hospital-based physicians are not required to be independently credentialed if those providers serve AmeriHealth VIP Care and AmeriHealth VIP Select members only through the hospital. All providers credentialed by AmeriHealth VIP Care and AmeriHealth VIP Select must also be enrolled with the Medicare program and, as such, must agree to comply with all pertinent Medicare regulations. 43

44 AmeriHealth VIP Care and AmeriHealth VIP Select Credentialing AmeriHealth VIP Care and AmeriHealth VIP Select credentialing/re- credentialing criteria and standards are consistent with the Centers for Medicare and Medicaid Services’ specific requirements and National Committee for Quality Assurance (NCQA) standards. Practitioners and facility/organizational providers are re-credentialed every three years. AmeriHealth VIP Care and AmeriHealth VIP Select works with the Council for Affordable Quality Healthcare (CAQH) to offer providers a Universal Provider Data source that simplifies and streamlines the data collection process for credentialing and re-credentialing. Through CAQH, providers submit credentialing information to a single repository, via a secure Internet site, to fulfill the credentialing requirements of all health plans that participate with CAQH. AmeriHealth VIP Care and AmeriHealth VIP Select’s goal is to have all providers enrolled with CAQH. 44

45 Medical Records Requirements Providers are required to maintain medical records in accordance with the Provider Manual. Requirements include, but are not limited to: Elements in the medical record are organized in a consistent manner, and the records are kept secure; Patient’s name or identification number is on each page of record; All entries are dated and legible; All entries are initialed or signed by the author; Personal and biographical data are included in the record; Current and past medical history and age-appropriate physical exam are documented and include serious accidents, operations and illnesses; Allergies and adverse reactions are prominently listed or noted as “none” or No Known Allergies “NKA”; Information regarding personal habits such as smoking and history of alcohol use and substance abuse (or lack thereof) is recorded when pertinent to proposed care and/or risk screening. 45

46 Access to Care AmeriHealth VIP Care and AmeriHealth VIP Select PCPs, specialists and behavioral health providers must meet standard guidelines as outlined in the Provider Manual to help ensure that AmeriHealth VIP Care and AmeriHealth VIP Select members have access to care. AmeriHealth VIP Care and AmeriHealth VIP Select’s Access Standards: Assure members’ accessibility to health care services Establish mechanisms for measuring compliance with existing standards Identify opportunities for the implementation of interventions for improving accessibility to health care services for members Office Accessibility The following areas are monitored by AmeriHealth VIP Care and AmeriHealth VIP Select to ensure physician access standards are continually met: PCP office hours must be clearly posted and reviewed with members during the initial office visit. The PCP is required to arrange for coverage of primary care services during absences due to vacation, illness or other situations that render the PCP unable to provide services. A Medicare- eligible PCP must provide the coverage to AmeriHealth VIP Care and AmeriHealth VIP Select members. 46

47 Provider Appointment Scheduling Appointment Scheduling AmeriHealth VIP Care and AmeriHealth VIP Select monitors access standards on an annual basis. Specialists who are serving in the PCP role (i.e. Internal Medicine, Family Practice, Pediatrics, or OB/GYN) are subject to the PCP Access Standards. Timely Access Standards for appointment availability for Primary Care Physicians (PCPs), Specialists and Behavioral Health providers are outlined on slide 48. Missed Appointment Tracking If a member misses an appointment with a provider, the provider should document the missed appointment in the member’s medical record. Providers should make at least three attempts to contact the member and determine the reason. The medical record should reflect any reasons for delays in performing the examination. Medical record should include any refusals by the member. 47

48 Physician Office Standards Primary Care and Behavioral Health Provider Access Standards: Emergent Care 24/7 Request Immediately or referred to ER Urgent Care Within two (2) calendar days of request Routine Care Within 14 calendar days of request Specialty Care Provider Access Standards: Routine Care Within 30 business days of request 48

49 Access to Care Access to After-Hours Care Members should have access to quality, comprehensive health care services 24 hours a day, 7 days a week. PCPs and behavioral health providers must have either an answering machine or an answering service for members during after-hours for non-emergent issues. The answering service must forward calls to the PCP or on-call provider, or instruct the member that the provider will contact the member within 30 minutes. When an answering machine is used after hours, the answering machine must provide the member with a process for reaching a provider after hours. The after-hours coverage must be accessible using the medical office’s daytime telephone number. For emergent issues, both the answering service and answering machine must direct the member to call 911 or go to the nearest emergency room. AmeriHealth VIP Care and AmeriHealth VIP Select monitor access to after-hours care on an annual basis by conducting a survey of PCP offices after normal business hours. 49

50 AmeriHealth VIP Referrals 50

51 AmeriHealth VIP Care and AmeriHealth VIP Select - Referrals Services that Require Referrals Specialist visits (except Direct Access Services – see below) Podiatry services Chiropractic Services Outpatient diagnostic procedures (unless otherwise specified) Ambulatory surgery center services Diabetes self-management training Direct Access Services that Do Not Require Referral Direct access to women’s specialists for routine and preventive services Direct access to mammography and influenza vaccinations Behavioral Health Services 51

52 AmeriHealth VIP Care and AmeriHealth VIP Select Referrals AmeriHealth VIP Care and AmeriHealth VIP Select Referrals Required Will affect provider payments Electronic submission and inquiry available on NaviNet. Hard Copy forms available at Three copies must be created - Referral copies must be kept in the member’s medical record, given to the member, and faxed or mailed to AmeriHealth VIP Care and AmeriHealth VIP Select. “Paper” form may be faxed or mailed. Mailing may cause delay in processing. 52

53 “Paper” Referral Form 53

54 NaviNet Referral Submission 54

55 AmeriHealth VIP Care and AmeriHealth VIP Select Referral Inquiry Specialists, hospitals and ancillaries can use Referral Inquiry to view and retrieve referrals on NaviNet. Simply log on to NaviNet (https://Navinet.Net) and select AmeriHealth VIP Care or AmeriHealth VIP Select from Plan Central.https://Navinet.Net Select Referral Inquiry and follow the steps to refer a patient or view referrals. Specialists, hospitals and ancillaries may also call Provider Services for AmeriHealth VIP Care or Provider Services for AmeriHealth VIP Select to inquire about a referral status. 55

56 NaviNet Referral Inquiry 56

57 Care Management

58 AmeriHealth VIP Care and AmeriHealth VIP Select offers a Care Management Program that is aimed at assisting members and providers in meeting the health care needs of our members. This program includes assistance with: coordinating transportation obtaining medications educational outreach developing an individual care plan for each member based on their goals. To assist members and providers AmeriHealth VIP Care and AmeriHealth VIP Select has created a Rapid Response Outreach Team. 58

59 Care Management The Rapid Response and Outreach Team (RROT) consists of Care Managers (Nurses and Social Workers) who are trained to help members investigate and overcome barriers to achieve their healthcare goals. Outreach Services include: Contacting members Educating members Calling Providers Calling Pharmacies Completing surveys and assessments to support special projects Providers may request RROT support directly by calling toll free at (855) , 8 am - 5 pm, Monday through Friday. 59

60 Medical Management Components Prior Authorization Utilization Review Case Management 60

61 Prior Authorization AmeriHealth VIP Care and AmeriHealth VIP Select requires Prior Authorization for certain services including, but not limited to: Elective / non-emergent air ambulance All out of network services (except emergency services) In-patient services Behavioral health care (mental health and substance abuse services) Home-based services Therapy and related services Transplants, including transplant evaluations All DME rentals and rent to purchase items High-Tech Outpatient Radiology Services For a complete list of services requiring prior authorization, please reference the Provider Manual. 61

62 AmeriHealth VIP Care and AmeriHealth VIP Select– The Model of Care AmeriHealth VIP Care and AmeriHealth VIP Select Model of Care is an Integrated Care Management Approach to health care delivery and coordination for Dual Eligible (Medicare/Medicaid) and Medicare eligible individuals. The Model of Care focuses on: Improving Health Outcomes Access to Essential Services/Affordable Care Coordination of Care through the Medical Home/Primary Care Physician Access to Preventive Services Seamless Transitions 62

63 The Model of Care – Structure and Roles Each member enrolls with a Medical Home/Primary Care Physician. The model includes care and support from health care providers, community agencies and service organizations. A 26-question Health Risk Assessment (HRA) is used to collect: –Physical and behavioral health history –Preventive care –Level of activity –Medication use The assessment is mailed with the Member’s welcome packet. Staff follow up with the Member by phone and mail to collect the data. Members receive an annual postcard reminding them to call AmeriHealth VIP Care and AmeriHealth VIP Select and update their HRA information. 63

64 Assessment and Plan of Care Development Data from multiple sources is used to develop the Plan of Care: Review of available claim and pharmacy history Data from the Health Risk Assessment Input from the member, Primary Care Physician and other providers 64

65 Interdisciplinary Care Team Each member has an Interdisciplinary Care Team to address his or her unique needs: Primary Care Physician/Medical Home Specialists – Physical & Behavioral Health Plan Nurses, Medical Directors, & Pharmacists Home Health Care Social Workers Community Mental Health Workers Physical, Speech & Occupational Therapy 65

66 The PCP/Medical Home The PCP/Medical Home plays an important role in the Interdisciplinary Team. Key responsibilities include: Assisting members in determining which services are necessary Connecting members to appropriate services Serving as a central communication point for the member’s care Reviewing the Plan of Care sent by AmeriHealth VIP Care and AmeriHealth VIP Select Providing feedback to AmeriHealth VIP Care and AmeriHealth VIP Select 66

67 Updates to the Plan of Care Updates are made routinely to the Plan of Care and come from multiple sources: Member or Provider call Updated HRA (annual) Care Transition (hospital, nursing home) Claim, Pharmacy or Utilization trigger Care episode 67

68 Identifying Vulnerable Sub-Populations AmeriHealth VIP Care and AmeriHealth VIP Select uses several mechanisms to identify vulnerable sub-populations, including: Claim data is analyzed to identify members with: Conditions targeted for chronic care improvement, such as diabetes, heart disease, COPD and renal disease Health needs, such as missing preventive care or recommended condition monitoring Utilization of emergency room and inpatient services is reviewed to identify members with opportunities for improved outpatient management Predictive Risk Scores are calculated using the DxCG methodology to identify members who are at risk for future avoidable health care episodes Health Risk Assessment data is reviewed for triggers identifying unmet health needs or the presence of chronic conditions 68

69 Chronic Condition Improvement Programs AmeriHealth VIP Care and AmeriHealth VIP Select offers several Chronic Care Improvement Programs: Diabetes Asthma Chronic Obstructive Pulmonary Disease Depression Members may self refer, be referred by a provider, or are identified through claims data analysis. Members or providers may contact the Member’s Case Manager for enrollment. 69

70 Clinical Practice Guidelines AmeriHealth VIP Care and AmeriHealth VIP Select’s Clinical Practice Guidelines are: Adopted from nationally-recognized organizations Serve as a guide to practitioners, but do not replace clinical judgment Available on and via hard-copy from Provider Serviceswww.amerihealthvipdc.com upon request Guideline Topics: 70 –Diabetes –Anxiety Disorder in Adults –COPD –Preventive Health Services –Depression –Coronary Vascular Disease –Hypertension –Immunization Schedules

71 Provider Focus on Preventive Services Medicare benefits cover an annual preventive physical examination. During each office visit, please remember to: Coach the member on appropriate physical activity Ask about falls and fall prevention Ask and coach on smoking cessation List all relevant diagnoses on the claim Check to see if the member needs: –Cancer Screening –Mammography or Colonoscopy –Glaucoma Testing –Flu or Pneumonia vaccine 71

72 High Risk Medication in the Elderly Medication alternatives should be evaluated prior to prescribing any of the following medications to an elderly member Antihistamines (promethazine, cyproheptadine, diphenhydramine, hydroxyzine) Skeletal Muscle Relaxants (cyclobenzaprine, methocarbamol, carisoprodol, chlorzoxazone) Oral Estrogens CNS Stimulants (amphetamines, anorexiants, methylphenidate) Urinary Anti-infectives (nitrofurantoin, nitrofurantoin macrocrystals, nitrofurantoin macrocrystals- monohydrate) Narcotics (pentazocine, meperidine) Others (dicylcomine, meprobamate, nifedipine IR, scopolamine, thioridazine, benzodiazepines, barbiturates) 72

73 Focus on Health Outcomes AmeriHealth VIP Care and AmeriHealth VIP Select’s goals include improving health outcomes for: Diabetes Care –HgbA,C and LDL testing/management –Diabetic retinal exam –Nephropathy screening –Blood pressure control Cardiac Care –LDL testing/management –Beta-blocker treatment after heart attack Blood Pressure Control COPD Management –Systemic corticosteroids and bronchodilator therapy for exacerbations Decreasing the use of high-risk drugs 73

74 Focus on Seamless Transition Everyone plays a role ensuring seamless transition: 74 AmeriHealth VIP Care and AmeriHealth VIP Select Staff Notify PCP/Medical Home of planned or unplanned transition for admission and at discharge. Contact members to verify plans, establish point of contact. Provide Plan of Care information to sending and receiving facility/provider, including changes at discharge. PCP Contact admitting physician to coordinate care. After discharge, review and reconcile medications. After discharge from an inpatient behavioral health stay, follow up with behavioral health provider. See the member at office visit post discharge. Hospital Send discharge summary/orders with medication list to AmeriHealth VIP Care and AmeriHealth VIP Select. Admitting Physician be available to speak with the Medical Home/PCP regarding member’s care needs.

75 Model of Care Evaluation The AmeriHealth VIP Care and AmeriHealth VIP Select’s Model of Care is evaluated using several data sources: Claims (medical, behavioral health, pharmacy) Authorizations HEDIS reports Member surveys (CAHPS, HOS) Practitioner and Facility surveys Provider workshops Complaint and grievance analysis 75

76 Communicating the Plan of Care on Transition The Transition Team collects and communicates information related to a member’s transition from one health care setting to another: 76 Transition Team With Member & Provider Input Sends Updated Plan of Care Medical Home/PCP Hospital/Facility/Agency Receiving the Member

77 Claims Submission

78 AmeriHealth VIP Care and AmeriHealth VIP Select – Claims AmeriHealth VIP Care and AmeriHealth VIP Select providers submit Medicare claims to AmeriHealth VIP Care and AmeriHealth VIP Select. Providers contractually have 365 days from the date of service to submit claims. Providers are encouraged to submit claims timely. Resubmissions must be submitted within 90 days from the date the original claim was processed. 78

79 AmeriHealth VIP Care and AmeriHealth VIP Select– Claims Providers may submit claims electronically through their current EDI Vendor if that vendor contracts with Emdeon, or the provider may contract directly with Emdeon. AmeriHealth VIP Care and AmeriHealth VIP Select Payer ID is Provider may submit Paper Claims for both products to: AmeriHealth VIP Care and AmeriHealth VIP Select Claims P.O. Box 307 Linthicum, MD Medicaid-only services and appropriate secondary payments (deductible, coinsurance, etc.) should be sent to District of Columbia Medicaid. 79

80 Electronic Data Interchange (EDI) To transmit claims electronically, contact your EDI software vendor and provide the AmeriHealth VIP Care and AmeriHealth VIP Select Payer ID: –Arrange electronic claims submission through your EDI vendor or through Emdeon Provider Support at: (877) Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) –Simplifies the payment process by providing fast, easy and secure payments –Reduces paper –Eliminating checks lost in the mail –Not requiring a change to your preferred banking partner – Enroll through our EFT partner, Emdeon Business Services or sign up via our fast and easy links on 80

81 AmeriHealth VIP Care and AmeriHealth VIP Select Payments and Remittance Advices Initially, all providers will receive AmeriHealth VIP Care and AmeriHealth VIP Select payments and remittance advices hard copy. Electronic Remittance Advices (ERA) and Electronic Funds Transfer (EFT) will be available soon after AmeriHealth VIP Care and AmeriHealth VIP Select goes live. 81

82 AmeriHealth VIP Care and AmeriHealth VIP Select– Provider Services

83 Provider Claims and Customer Service Provider Services for AmeriHealth VIP Care Provider Services for AmeriHealth VIP Select Same Number for both Member and Provider Provider’s choose Option 2  Verify member eligibility, PCP assignment, obtain member ID # (Option 1)  Provider claims issue resolution or adjustments (Option 2)  Obtain and verify prior authorizations (Option 3)  Prescription drugs, prescription prior authorizations, and exceptions (Option 4)  Assistance in coordinating care (Option 5) 83

84 Provider Account Executives AmeriHealth VIP Care and AmeriHealth VIP Select pride themselves on having a provider representative available to providers – an Account Executive. Your Account Executive will provide on-site education, issue resolution, and assistance with credentialing. AmeriHealth VIP Care and AmeriHealth VIP Select will communicate through on-site orientations, routine site visits, provider workshops, letters, the Provider Manual, the provider resource center on the website and provider newsletters. A listing of AmeriHealth VIP Care and AmeriHealth VIP Select Account Executives is available on our website at 84

85 The Provider Manual The AmeriHealth VIP Care and AmeriHealth VIP Select Provider Manual is on our website at The Provider Manual is an extension of your provider contract with AmeriHealth VIP Care and AmeriHealth VIP Select Identifies key provider roles & responsibilities Member rights & responsibilities AmeriHealth VIP Care and AmeriHealth VIP Select’s quality programs, credentialing & utilization management AmeriHealth VIP Care and AmeriHealth VIP Select’s Model of Care Claims protocols 85

86 Provider Marketing Compliance The Centers for Medicare and Medicaid Services (CMS) is concerned with provider marketing activities for the following reasons: Providers may not be fully aware of benefits & costs and may inadvertently misinform a member Providers may confuse the member regarding their role as their health care provider versus acting as an AmeriHealth VIP Care and AmeriHealth VIP Select representative Providers may face a conflict of interest 86

87 Acceptable Provider Marketing Practices Examples of Acceptable Provider Marketing Practices Provide the names of Medicare Advantage plan sponsors with which they contract and/or participate. Provide information and assistance in applying for the Low Income Subsidy (LIS). Make available and/or distribute AmeriHealth VIP Care and AmeriHealth VIP Select marketing materials developed by AmeriHealth VIP Care and AmeriHealth VIP Select. Refer patients to other sources of information, such as SHIPs, the Medicare Advantage plan’s marketing representatives, the State Medicaid Office, local Social Security Office, CMS’ website at or MEDICARE.http://www.medicare.gov/ Share information with patients from CMS’ website, including the “Medicare and You” Handbook or “Medicare Options Compare” (from or other documents that were written by or previously approved by CMS.http://www.medicare.gov 87

88 Cultural and Linguistic Requirements Our Cultural Competency program, has been built upon 14 of the national standards for Culturally and Linguistically Appropriate Services (CLAS), as set forth by the Federal Department of Health and Human Services. As a provider of health care services who receives Federal financial payment through the Medicare and Medicaid programs, you are responsible to make arrangements for: Standard 4 - Language assistance at no cost to patients/consumers Standard 5 - Signage and written notices of interpreter services available at no cost Standard 6 - Use of qualified/certified interpreters and translators Standard 7 - Translation of vital documents Language assistance information should be at all points of contact and during all hours of operation. 88

89 Cultural and Linguistic Requirements Providers are required to: Provide written and oral language assistance at no cost to AmeriHealth VIP Care and AmeriHealth VIP Select members with limited English proficiency or other special communication needs, at all points of contact and during all hours of operation. Language access includes the provision of competent language interpreters, upon request. Provide members verbal or written notice (in their preferred language or format) about their right to receive free language assistance services. Post and offer easy-to-read member signage and materials in the languages of the common cultural groups in your service area. Vital documents such as patient information forms and treatment consent forms, must be made available in other languages and formats. 89

90 Available Cultural and Linguistic Services We have an arrangement for participating AmeriHealth VIP Care and AmeriHealth VIP Select providers to access telephonic interpretation at a discounted rate. For more information, please contact Provider Services for AmeriHealth VIP Care or Provider Services for AmeriHealth VIP Select Providers who are unable to arrange for translation services for a Limited English Proficiency (LEP), Limited Language Proficiency (LLP) or sensory impaired member should contact Member Services for AmeriHealth VIP Care or Member Services for AmeriHealth VIP Select and a representative will help locate a professional interpreter who communicates in the member’s primary language. Providers may request a full copy of AmeriHealth VIP Care and AmeriHealth VIP Select’s Cultural Competency Plan free of charge, or, access this information in the Provider Manual. For additional information or to view the CLAS standards go to For language assistance services, contact us at (866) or go to 90

91 Fraud, Waste and Abuse Designed in accordance with federal rules and regulations, AmeriHealth VIP Care and AmeriHealth VIP Select’s compliance program is aimed at ensuring compliance with all Medicare Advantage program requirements and preventing and detecting activities that constitute fraud, waste and abuse. AmeriHealth VIP Care and AmeriHealth VIP Select has developed a Compliance and Fraud, Waste and Abuse (FWA) online training program. The program includes: Compliance requirements FWA policies and procedures Investigation of unusual incidents Implementation of corrective action AmeriHealth VIP Care and AmeriHealth VIP Select has provider training materials available via its website: Materials, which are available by contacting the Provider Network Management team, include information regarding the following… 91

92 Fraud, Waste and Abuse Fraud “Fraud” is an intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to that person or another person. The term includes any act that constitutes fraud under applicable federal or state law. As applied to the federal health care programs (including the Medicaid and Medicare programs), health care fraud generally involves a person or entity’s intentional use of false statements or fraudulent schemes (such as kickbacks) to obtain payment for, or to cause another to obtain payment for, items or services payable under a federal health care program. Some examples of fraud include: Billing for services not furnished; Soliciting, offering or receiving a kickback, bribe or rebate; or Violations of the physician self-referral prohibition. 92

93 Fraud, Waste and Abuse Waste “Waste” means to use or expend carelessly, extravagantly, or to no purpose. Abuse “Abuse” is defined as provider practices that are inconsistent with generally accepted business or medical practice and that result in an unnecessary cost to the Medicaid or Medicare programs or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the Medicaid or Medicare programs. In general, program abuse, which may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicare and Medicaid programs. Some examples of abuse include: Charging in excess for services or supplies; Providing medically unnecessary services; or Providing services that do not meet professionally recognized stand ards. 93

94 Fraud, Waste and Abuse False Claims Act The Federal False Claims Act (FCA) is a federal law that applies to fraud involving any contract or program that is federally funded, including Medicare and Medicaid. Health care entities that violate the Federal FCA can be subject to civil monetary penalties ranging from $5,000 to $10,000 for each false claim submitted to the United States government or its contactors, including state Medicaid agencies. The Federal FCA contains a “qui tam” or whistleblower provision to encourage individuals to report misconduct involving false claims. The qui tam provision allows any person with actual knowledge of allegedly false claims submitted to the government to file a lawsuit on behalf of the U.S. Government. The FCA protects individuals who report under the qui tam provisions from retaliation that might result from filing an action under the Act, investigating a false claim, or providing testimony for or assistance in a federal FCA action. 94

95 Fraud, Waste and Abuse Reporting and Preventing Fraud, Waste and Abuse Compliance with state and federal laws and regulations is a priority of AmeriHealth VIP Care and AmeriHealth VIP Select. If you or any entity with which you contract to provide services become concerned about or identifies potential fraud, waste or abuse, please contact: AmeriHealth VIP Care and AmeriHealth VIP Select toll-free at (866) ; or you may also send an to the Medicare Compliance Officer at to report potential FWA; or Inspector General: HS-TIPS ( ) Report suspected Medicaid Fraud or possible abuse, neglect or financial exploitation of patients in Medicaid facilities by contacting: Medicaid Fraud Control Unit of D.C. Office of D.C. Inspector General th St., N.W. 5th Floor Washington, DC Phone (202) Fax (202)

96 Communication Updates and outcomes are communicated through several methods: AmeriHealth VIP Care and AmeriHealth VIP Select’s Website – Quality and Satisfaction Updates Member News Bulletin Provider News Bulletin Provider Workshops – presentations are interactive via the website, face-to- face workshop presentations and provider site visits. All communications are available hard copy upon request or via the AmeriHealth VIP Care and AmeriHealth VIP Select’s website at 96

97 Questions For additional questions, please contact your Provider Account Executive or Provider Services. AmeriHealth VIP Care AmeriHealth VIP Select

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