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Amerigroup Community CareNJHA Managed Medicaid SeminarMarch 2019Coverage provided by Amerigroup Inc.March 2019
Introduction Lynda Grajeda, Director of Network ManagementAnn Basil, Behavioral Health AdministratorMaribel Medenilla, Behavioral Health Provider ContractingKeisha Woodson, Manager MLTSS
MLTSS System Changes 2018-2019 Personal Preference Program: Amerigroup transitionedpayment to the personal preference fiscal intermediaryfrom invoicing to claims in 2018. TBI code changes: Per State guidance issued January2018, specific TBI codes have been changed to meet CMSrequirements. Nursing Home Taxonomy Code (2019): Effective4/1/2019, Amerigroup will enforce policy requirement; allclaims filed using Revenue Code 0100 (skilled or custodial)will require appropriate standard taxonomy codes todetermine accurate payment.
MLTSS AuthorizationsReminders: All “waiver” services for MLTSS members require authorization throughthe member’s plan of care. DMAHS Continuity of Care guidelines apply. IP admissions must be requested at least 72 hours in advance. Amerigroup must be notified of existing LTC admits within 72 hours ofeligibility change. Members receiving MLTSS will be permitted to see all current providerson their approved service plan, including any non-network providers,until an assessment and service plan is completed and either agreedupon by the member or resolved through the appeals or fair hearingprocess.Precert request via faxFax numberPCA/Medical Day for all Amerigroup members888.240.4716MLTSS “Waiver” Services – MLTSS members only888.240.4717Hospice - MLTSS members only888.240.4717Hospice - Amerivantage members only866.805.4589Hospice - All other Amerigroup members800.964.3627
MLTSS Claims Provider Solutions: 1-800-454-3730 NJ MLTSS Provider Help: nj1mltssprovhelp@amerigroup.com MLTSS services will not be reduced, modified or terminated in theabsence of a new/up-to-date assessment of needs or plan of care thatwould support any service reduction, modification or termination. Amerigroup will notify providers within 24 hours ofreduction/termination determination via fax. Member/providerletters will follow. Amerigroup does not have any reported trends or process changes inrecent denials/appeals.
Role of Provider Solutions To deliver a best-in-class provider experience that differentiatesAmerigroup from our competitors and positions us as the preferredpartner for providers – across all lines of business and all markets. To support and collaborate with our providers in serving ourmembers.Our Provider Solutions staff serves the following functions: Provider outreach Provider education and training Engagement in quality initiatives Provider customer service Building and maintaining the provider network
Online Provider Tools and Resourceshttps://providers.amerigroup.com/NJ
Provider Self-Service WebsiteRegistration and login are not requiredfor access to the following: Claims forms Precertification Lookup Tool Provider manuals Clinical Practice Guidelines News and announcements Provider directories Fraud, waste and abuse information
Provider ManualThe provider manual is a key support resource for: Precertification requirements. An overview of covered services. The member eligibility verification process. Member benefits. Access and availability standards. The grievances and appeals process.
Provider Solutions Contacts Provider Solutions: 1-800-454-3730 Provider Self-Service Website:https://providers.amerigroup.com/NJ NJ Credentialing Inbox: nj1credentialing@amerigroup.com Provider Demographic om WebPortal Issues: 757-769-7802 Availity: 1-800-AVAILITY Appeals Inquiry - 866-696-4701 EDI Issues: 1-800-590-5745
Behavioral Health Update OBAT – Office Based Addiction Treatment, also known as the MATrxProgram. The goals of the MATrx program are to increase statewidecapacity for the provision of MAT to patients with substance usedisorder; increase provider capacity, increase quality throughcontinuing education, training and consultation; connect office basedaddiction treatment providers with behavioral health supports, andimprove treatment retention through the use of peer support and carecoordination “Navigator” services. PA for MAT removal - Effective 4/1/2019, no prior authorization shallbe allowed for medications and/or bundled services that includeadministering medication for the treatment of opioid use disorder.Safety edits, posted as a result of prospective drug utilization review(DUR), are allowed. For claims billed through the pharmacy program,formulary preferences may be utilized.
Role of Care Management Care Management emphasizes prevention, continuity of care andcoordination of care, which advocates for, and links enrollees to, services asnecessary across providers and settings. At a minimum, Care Management functions must include, but are not limitedto: Early identification of enrollees who have or may have special needs; Assessment of an enrollee's risk factors; Development of a plan of care; Referrals and assistance to ensure timely access to providers; Coordination of care actively linking the enrollee to providers, medicalservices, residential, social, behavioral and other support services whereneeded; Monitoring; Continuity of care; and Follow-up and documentation
Case Management Process Members are referred to CM from the following sources:ooooooooMember ServicesNurse HelpLineInpatient Census & Discharge Planning ProcessDisease te Agencies or External Case Workers Members are referred to Amerigroup’s care management team wherethey are screened, assessed, stratified and managed according to their riskstratification.13
Role of Utilization Management (UM) UM performs technical and administrative work required to evaluate the necessity,appropriateness, and efficiency of medical services, procedures, and facilities: Home Health Care Home Therapy (Physical, Occupational and Speech Therapy) Durable Medical Equipment Non-Participating Provider Requests Specialty Injectables Air Transportation Transfer/Placement to Free Standing Skilled Nursing Facility/RehabilitationCenter Out-of-State Transfers for Inpatient Admission Performs inpatient medical necessity and concurrent reviews and coordinates withthe discharge planning team members, facility UM departments, physicians, andmembers to coordinate timely discharges. Provides appropriate referral andscheduling assistance.14
Concurrent Review Process To submit clinical information - Fax # 877-244-1703 Nurses assigned to specific hospitals for concurrent review. Use MCG criteria for determinations. Adverse determinations sent toMedical Director for review. Concurrent Review nurses conduct discharge planning in conjunction withCare Management (CM) on open cases and refer cases to CM asappropriate. CM conducts post discharge management of selected cases. Clinical Rounds conducted with Medical Director weekly. Daily Logs are sent to hospitals with summary of all inpatient admits.15
Emergency Room Triage We believe that managed care organizations (MCOs) and healthcareproviders have a shared responsibility to provide the right care at theright time and in the most appropriate care setting. The recent Emergency Room Triage fee law enacted by the Legislaturedid not directly impact managed care contracts as the law pertainedto the fee for service (FFS) program only. Our participating agreements with hospitals have their own individualterms and conditions around compensation for emergency room careand are unaffected. For our non-participating encounters that this policy may apply; weare working to implement the new law to both properly load the listof codes that are considered low acuity as well as to make theappropriate system edits to recognize the population exclusions in theguidance.
Amerigroup from our competitors and positions us as the preferred partner for providers – across all lines of business and all markets. To support and collaborate with our providers in serving our members. Our Provider Solutions staff serves the followin
