PARTICIPATING PROVIDER
ORIENTATION
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)
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AmeriHealth VIP Care and AmeriHealth
VIP Select are members of the
AmeriHealth Caritas Family of
Companies - the industry leader in
managing medically complex members.
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We are expanding our membership to
continue our vision and mission to
provide healthcare services to the
underserved.
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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.
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AmeriHealth VIP Select enables us to
offer this same level of service to the
traditional Medicare member.
Who We Are
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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
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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:
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Handle more than 2.25 million member and provider calls annually in our
24/7 call centers.
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Process an average of 2.1 million claims each month.
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Receive more than 87 percent of provider claims electronically with
automatic adjudication rates of more than 81 percent.
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Why AmeriHealth VIP Care and AmeriHealth VIP Select?
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:
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 2012-2013, issued September 20, 2012.
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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.
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Mission
Statement
We help people get care,
stay well and build healthy
communities.
We have a special concern
for those who are poor.
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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
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Will accept only those beneficiaries with dual Medicaid/Medicare eligibility.
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Members can enroll or change plans at any time.
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Members can enroll by calling member services at 888-996-0799.
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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.
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Summary of AmeriHealth VIP Care’s Benefit Package
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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
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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
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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
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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
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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
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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
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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
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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) 996-0799 to
arrange for membership
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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) 327-5050
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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
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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)-996-0899.
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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.
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Summary of AmeriHealth VIP Select’s Benefit Package
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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
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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
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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
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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
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AmeriHealth VIP Select Supplemental Benefits –Hearing
HEARING SERVICES
• $0 copay for Medicare-covered diagnostic hearing
exams
• Routine services are not a covered benefit
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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) 327-5050
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Member
Eligibility
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Member Rights and Responsibilities
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.
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Member Welcome Packet
AmeriHealth VIP Care and AmeriHealth VIP Select Member welcome packets
includes:
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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
888-996-0799 or AmeriHealth VIP Select member services at 888-996-0899.
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Member PCP Selection
• Members may select a new PCP at any point in time by
calling AmeriHealth VIP Care member services at 888996-0799 or AmeriHealth VIP Select member services at
888-996-0899.
• 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.
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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 888-9960799
• Provider Services for AmeriHealth VIP Select 888-9960899
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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.net
Informational website
– www.NaviNet.net
– NaviNet Web Portal: www.navinet.net Phone: (888) 482-8057
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
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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
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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 email to NaviNet Support at NaviNet@NaviNet.net
All Support Cases or requests submitted via email should include:
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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.)
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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 888-996-0799 or Provider Services for
AmeriHealth VIP Select 888-996-0899 to verify eligibility.
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Member Eligibility via NaviNet
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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)
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AmeriHealth VIP Care Member Panel Roster
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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.
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Provider Participation
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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.
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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.
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AmeriHealth VIP Care and AmeriHealth VIP Select Credentialing
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AmeriHealth VIP Care and AmeriHealth VIP Select credentialing/recredentialing 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.
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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.
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Access to Care
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:
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Assure members’ accessibility to health care services
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Establish mechanisms for measuring compliance with existing standards
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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:
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PCP office hours must be clearly posted and reviewed with members during the initial office
visit.
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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 Medicareeligible PCP must provide the coverage to AmeriHealth VIP Care and AmeriHealth VIP Select
members.
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Provider Appointment Scheduling
Appointment Scheduling
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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.
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Timely Access Standards for appointment availability for Primary Care Physicians (PCPs),
Specialists and Behavioral Health providers are outlined on slide 48.
Missed Appointment Tracking
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If a member misses an appointment with a provider, the provider should document the missed
appointment in the member’s medical record.
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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.
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Medical record should include any refusals by the member.
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Physician Office Standards
Primary Care and Behavioral
Health Provider Access Standards:
Specialty Care Provider Access
Standards:
Routine Care
Emergent Care 24/7 Request
•
• Within 30 business days of request
Immediately or referred to ER
Urgent Care
• Within two (2) calendar days of
request
Routine Care
• Within 14 calendar days of
request
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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.
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PCPs and behavioral health providers must have either an answering machine or an
answering service for members during after-hours for non-emergent issues.
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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.
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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.
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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.
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AmeriHealth VIP Referrals
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AmeriHealth VIP Care and AmeriHealth VIP Select - Referrals
Services that Require Referrals
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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
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AmeriHealth VIP Care and AmeriHealth VIP Select Referrals
AmeriHealth VIP Care and AmeriHealth VIP Select
• Referrals Required
Will affect provider payments
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Electronic submission and inquiry available on NaviNet.
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Hard Copy forms available at www.amerihealthvipdc.com.
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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.
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“Paper” form may be faxed or mailed. Mailing may cause delay in
processing.
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“Paper” Referral Form
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NaviNet Referral Submission
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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.
• 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 888-9960799 or Provider Services for AmeriHealth VIP Select
888-996-0899 to inquire about a referral status.
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NaviNet Referral Inquiry
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Care Management
Care Management
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:
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coordinating transportation
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obtaining medications
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educational outreach
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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.
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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:
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Contacting members
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Educating members
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Calling Providers
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Calling Pharmacies
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Completing surveys and assessments to support special projects
Providers may request RROT support directly by calling toll free at
(855) 707-0854, 8 am - 5 pm, Monday through Friday.
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Medical Management Components
Prior
Authorization
Utilization
Review
Case
Management
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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.
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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
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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.
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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
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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
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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
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
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Identifying Vulnerable Sub-Populations
AmeriHealth VIP Care and AmeriHealth VIP Select uses several mechanisms to identify
vulnerable sub-populations, including:
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Claim data is analyzed to identify members with:
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Conditions targeted for chronic care improvement, such as diabetes, heart disease,
COPD and renal disease
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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
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Predictive Risk Scores are calculated using the DxCG methodology to identify
members who are at risk for future avoidable health care episodes
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Health Risk Assessment data is reviewed for triggers identifying unmet health needs
or the presence of chronic conditions
68
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
Clinical Practice Guidelines
AmeriHealth VIP Care and AmeriHealth VIP Select’s Clinical Practice
Guidelines are:
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Adopted from nationally-recognized organizations
•
Serve as a guide to practitioners, but do not replace clinical judgment
•
Available on www.amerihealthvipdc.com and via hard-copy from Provider Services
upon request
Guideline Topics:
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Diabetes
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Depression
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Anxiety Disorder in Adults
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Coronary Vascular Disease
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COPD
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Hypertension
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Preventive Health Services
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Immunization Schedules
70
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
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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 macrocrystalsmonohydrate)
Narcotics (pentazocine, meperidine)
Others (dicylcomine, meprobamate, nifedipine IR, scopolamine, thioridazine, benzodiazepines,
barbiturates)
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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
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Focus on Seamless Transition
Everyone plays a role ensuring seamless transition:
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
Hospital
Contact admitting physician to
coordinate care.
Send discharge
summary/orders with
medication list to AmeriHealth
VIP Care and AmeriHealth VIP
Select.
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.
Admitting Physician be
available to speak with the
Medical Home/PCP regarding
member’s care needs.
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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
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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:
Transition Team
With Member & Provider Input
Sends Updated
Medical Home/PCP
Hospital/Facility/Agency
Receiving the Member
Plan of Care
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Claims Submission
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.
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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 77007
• Provider may submit Paper Claims for both products to:
AmeriHealth VIP Care and AmeriHealth VIP Select
Claims
P.O. Box 307
Linthicum, MD 21090-0307
Medicaid-only services and appropriate secondary payments (deductible,
coinsurance, etc.) should be sent to District of Columbia Medicaid.
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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: 77007.
– Arrange electronic claims submission through your EDI vendor or through Emdeon Provider
Support at: (877) 363-3666
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 www.amerihealthvipdc.com
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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.
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AmeriHealth VIP Care and AmeriHealth
VIP Select– Provider Services
Provider Claims and Customer Service
Provider Services for AmeriHealth VIP Care 888-996-0799
Provider Services for AmeriHealth VIP Select 888-996-0899
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)
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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 www.amerihealthvipdc.com
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The Provider Manual
The AmeriHealth VIP Care and AmeriHealth VIP Select Provider Manual is
on our website at www.amerihealthvipdc.com.
•
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
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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
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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 http://www.medicare.gov/ or 1-800-MEDICARE.
•
Share information with patients from CMS’ website, including the “Medicare and You”
Handbook or “Medicare Options Compare” (from http://www.medicare.gov), or other
documents that were written by or previously approved by CMS.
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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.
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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.
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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 888-247-0373 or Provider Services
for AmeriHealth VIP Select 888-247-0391.
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 888-996-0799 or Member Services for AmeriHealth
VIP Select 888-996-0899 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
http://www.minorityhealth.hhs.gov/. For language assistance services, contact us at (866) 5335490 or go to www.amerihealthvipdc.com
.
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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: www.amerihealthvipdc.com.
Materials, which are available by contacting the Provider Network
Management team, include information regarding the following…
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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.
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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 standards.
93
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.
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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) 833-9718; or you may also
send an e-mail to the Medicare Compliance Officer at TMapp@amerihealthcaritas.com to report
potential FWA; or
•
Inspector General: 1-800-HS-TIPS (1-800-447-8477)
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
717 14th St., N.W.
5th Floor
Washington, DC 20005
Phone (202) 727-8008
Fax (202) 727-5937
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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-toface 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
www.amerihealthvipdc.com
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Questions
For additional questions, please contact your Provider
Account Executive or Provider Services.
• AmeriHealth VIP Care 888-996-0799
• AmeriHealth VIP Select 888-996-0899
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