PRECERTIFICATION AND NOTIFICATION GUIDELINES 88

24/7 precertification and notification:  Online at providers.amerigroup.com/KS  By fax to 1-800-964-3627

 By call to1-800-454-3730

24/7 pharmacy precertification and notification:  Online at www.express-scripts.com

 By fax to 1-800-601-4829  By call to 1-855-201-7170

Medical Injectable precertification and notification  By fax to 1-855-363-0728

 By call to 1-800-454-3730

Please provide the following information with your requests:  Member or Medicaid ID

 Member’s Social Security number if available  Member’s date of birth

 Legible name of referring provider

 Legible name of person referred to provider  Number of visits/services

 Date(s) of service  Diagnosis

 Clinical information

Behavioral (Mental) Health/Substance Use Disorder Services

Precertification is not required for basic behavioral health services provided in a PCP or medical office.

Inpatient SUD, detox and behavioral health services including Psychiatric Residential Treatment Facilities (PRTF) services require precertification.

For information on precertification requirements for behavioral health specialty services, please see Appendix B.

Cardiac Rehabilitation Precertification is required for all services.

Chemotherapy  Precertification is not required for procedures performed in the following outpatient settings: office, outpatient hospital or ambulatory surgery center.

 Precertification is required for inpatient chemotherapy as part of the inpatient admission.

To check the coverage and precertification requirement status for oncology drugs and adjunctive agents, please refer to the Precertification Lookup tool on our provider self-service site.

Circumcision Precertification is not required.

Dental Services Precertification may be required for dentists contracted with Scion Dental. Please call Scion Dental at 1-855-812-9206.

Dermatology  Precertification is not required for a network provider for E&M, testing or procedures.

 Cosmetic services or services related to previous cosmetic procedures are not covered. For code-specific requirements, visit our provider website.

Diagnostic Testing  Precertification is not required for routine diagnostic testing.

 Precertification is required for MRA, MRI, CAT scan, nuclear cardiology and video EEG.

National Imaging Associates (NIA) manages preauthorization for computerized tomography, computerized axial tomography, nuclear cardiology, magnetic resonance imaging, magnetic resonance angiogram. They can be contacted at 1-800-642-7565.

Durable Medical Equipment (DME)

Precertification is not required for:

 Glucometers and nebulizers

 Dialysis and ERSD equipment

 Gradient pressure aid

 Light therapy

 Sphygmomanometers

 Walkers

Precertification is required for:

 All rental DME equipment

 Certain DME

For code-specific requirements, visit our provider website. Request precertification with a Certificate of Medical Necessity (CMN) — available on our website — or by submitting a physician order and Amerigroup Referral and Authorization Request form.

You must send a complete CMN with each claim for:

 Hospital beds

 Motorized wheelchairs

 Manual wheelchairs

 Continuous Positive Airway Pressure (CPAP)

 Lymphedema pumps

 Osteogenesis stimulators

 Transcutaneous Electrical Nerve Stimulators (TENS)

 Seat lift mechanism

 Power-Operated Vehicles (POV)

 External infusion pump

 Parenteral nutrition

 Enteral nutrition and oxygen

We must agree on HCPCS and/or other codes for billing, and we require you to use appropriate modifiers (NU for new equipment, RR for rental equipment).

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)/KAN Be Healthy Visit

 Member may self-refer.

 Use the American Academy of Pediatrics Periodicity Schedule and AAPD Recommendations for Preventive Pediatric Dental Care, and document visits.

 Note: vaccine serum is received under the Vaccine for Children (VFC) program for KanCare members age 18 and under.

 Precertification is not required. Educational Consultation Precertification is not required. Emergency Room Precertification is not required.

We must be notified within 24 hours or the next business day if a member is admitted into the hospital through the emergency room. We will not deny these claims, however, if notification is not received.

ENT Services (Otolaryngology) Precertification is not required for a network provider for:

 E&M

 Testing

 Certain procedures Precertification is required for:

 Tonsillectomy and/or adenoidectomy

 Nasal/sinus surgery

 Cochlear implant surgery and services

For code-specific requirements, visit our provider website. Family Planning/Sexually

Transmitted Infections (STI) Care

Members may self-refer to any in-network or out-of-network provider. Encourage patients to receive family planning services in network to ensure continuity of service. Precertification is not required.

Gastroenterology Services Precertification is not required for a network provider for:

 E&M

 Testing

 Certain procedures Precertification is required for:

 Bariatric surgery

 Insertion, removal, and/or replacement of adjustable gastric restrictive devices and subcutaneous port components

 Upper endoscopy

For code-specific requirements, visit our provider website. Gynecology

(also see Obstetrical Care)

Precertification is not required for a network provider for:

 Testing

 Certain procedures

Hearing Aids Precertification is required for digital hearing aids. Hearing Screening No precertification is required for:

 Diagnostic and screening tests

 Hearing aid evaluations

 Counseling

Home Health Care Precertification is required. Covered services include:

 Skilled nursing

 Home health aide

 Physical, occupational and speech therapy services

 Physician-ordered supplies

Drugs and DME require separate precertification. Hospice Care Precertification is required.

Hospital Admission Precertification is required for:

 Elective admissions

 Some same-day/ambulatory surgeries

Preadmission testing must be performed by an Amerigroup preferred lab vendor or network facility outpatient department. Please see our provider directory for a complete listing.

We do not cover:

 Rest cures

 Personal comfort and convenience items

 Services and supplies not directly related to patient care (telephone charges, take-home supplies, etc.)

Laboratory Services (Outpatient)

Precertification is required for all laboratory services furnished by non‐network providers except hospital laboratory services in the event of an emergency medical condition.

Submit all laboratory tests to Quest Diagnostics or LabCorp, the preferred lab providers for all Amerigroup members. Contact Quest or LabCorp at the numbers below to receive a Quest or LabCorp specimen drop box.

For more information, testing solutions and services or setting up an account, contact either:

 Quest Diagnostics: 1-866-MY-QUEST (1-866-697-8378) or

 LabCorp: 1-800-345-4363

Medical Supplies Precertification is not required for disposable medical supplies. Medical Injectables Amerigroup covers most specialty drugs under the pharmacy benefit.

Express Scripts Specialty Pharmacy Services is our preferred provider; however these drugs can be obtained through any pharmacy in our network that dispenses these medications.

For a complete list of specialty drugs, please visit our provider website. Some medical injectables require prior authorization when covered under the medical benefit and administered in the physician’s office.

Neurology Precertification is not required for a network provider for:

 E&M

 Testing

 Certain other procedures Precertification is required for:

 Neurosurgery

 Spinal fusion

 Artificial intervertebral disc surgery

For code-specific requirements, visit our provider website.

Observation Precertification is not required for in-network observation. If your observation results in an admission, you must notify us within 24 hours or on the next business day.

Obstetric Care We only require notification for obstetric care. Precertification is not required for:

 Obstetric services and diagnostic testing

 Obstetric visits

 Certain diagnostic tests and lab services by a participating provider

 Prenatal ultrasounds

 Labor and delivery You must notify:

 Amerigroup at the first prenatal visit

 Amerigroup within 24 hours of delivery with newborn information (please include baby’s mode of delivery, gender, weight in grams, gestational age in weeks and disposition at birth)

 Amerigroup of the mother's pediatrician selection for continuity of care

 Kansas Department of Health and Environment (KDHE) regarding birth within 24 hours to generate a request for a state-issued Medicaid ID number Obstetric case management programs are available.

In network: We will not deny claims payment based solely on lack of notification for obstetric care (at first visit) and obstetric admissions not exceeding 48 hours after vaginal delivery and 96 hours after Cesarean section.

Out-of-network: If Amerigroup is not notified, our claims system will deny these claims.

Ophthalmology  Precertification is not required for E&M, testing and certain procedures.

 Precertification is required for repair of eyelid defects.

 For code-specific requirements, visit our provider website.

 We do not cover services that are considered to be cosmetic.

 For Ophthalmology services, call Ocular Benefits at 1-855-812-9214. Oral Maxillofacial See Plastic/Cosmetic/Reconstructive Surgery.

Out-of-Area/Out-of-Network Care

Precertification is required, except for emergency care, EPSDT screening, family planning and OB care.

Outpatient/Ambulatory Surgery Precertification requirement is based on procedure performed. For code-specific requirements, visit our provider website.

Pain Management/Physiatry/ Physical Medicine and Rehabilitation

Precertification is required for non-E&M-level testing and procedures. For code-specific requirements, visit our provider website.

Plastic/Cosmetic/Reconstructive Surgery (including Oral

Maxillofacial Services)

Precertification is not required for:

 E&M services

 Oral maxillofacial

 All other services

 Trauma to the teeth

 Oral maxillofacial medical and surgical conditions

 TMJ

We do not cover:

 Services considered cosmetic in nature

 Services related to previous cosmetic procedures

Reduction mammoplasty requires our medical director’s review. For code-specific requirements, visit our provider website.

Radiology See Diagnostic Testing. Rehabilitation Therapy (Short

Term): OT, PT, RT and ST

Precertification is not required for:

 Evaluation

 Initial visit

Precertification is required for:

 Treatments

 Inpatient rehabilitation

Therapy to improve a child’s ability to learn and participate in school should be evaluated for school-based therapy. Therapies for rehabilitative care are covered as medically necessary.

Sleep Studies Precertification is required. Sterilization Precertification is not required for:

 Sterilization

 Tubal ligation

 Vasectomy

We require a sterilization consent form for claims submissions. We do not cover reversal of sterilization.

Urgent Care Center Precertification is not required for a participating facility. Waiver Services Precertification is required for all waiver-related services.

Well-woman Exam Precertification is not required. We cover one well-woman exam per year when performed by her PCP or an in-network GYN. It includes:

 Examination

 Routine lab work

 STI screening

 Mammogram screening for women age 40 and older; precertification is required for women age 39 and younger

 Pap smears

Members can receive family planning services without precertification at any qualified provider. Encourage patients to receive family planning services in-network to ensure continuity of service.

Revenue (RV) Codes Precertification is required for services billed by facilities with RV codes for:

 Inpatient, including psychiatric admissions, community medical detox and PRTFs

 OB

 Home health care

 Hospice

 CT and nuclear cardiology

 Chemotherapeutic agents

 Pain management

 Rehabilitation, short term (speech therapy)

 Specialty agents

– Refer to the Quick Tools on our website for code-specific precertification requirement status

For a complete list of specific RV codes, visit providers.amerigroup.com/KS.

We have clinical staff available 24 hours a day, 7 days a week to accept precertification requests. When a medical request is received, we:

 Verify our member’s eligibility and benefits  Determine the appropriateness of the request  Issue you a reference number

For urgent requests, we give you a decision within one business day. If documentation is not complete, we will ask for additional necessary documentation.

If your request is denied by our medical director, you will have the opportunity to discuss your case with him or her before the final determination. We will mail a denial letter to the hospital; the member’s PCP and the member and include the member’s appeal and fair hearing rights and process.

In document Provider Manual. Kansas n providers.amerigroup.com/ks (Page 95-101)