What You Need to Know About Balance Billing
As a reminder, based on the terms of your Participating Provider Agreement with AmeriChoice, balance billing AmeriChoice members for covered services is prohibited and violates New Jersey law and regulation. You may, however, collect applicable copayments, deductibles and coinsurances as appropriate. Applicable law provides that a medical assistance (“Medicaid”) member is not personally liable for any payment arising from any medical services provided to him/her, and any attempt to collect monies from a member is a violation of state law and the Federal Medicaid and Medicare Act. See N.J.A.C. § 10:74-8.7 (If amanaged care provider renders a covered service to a Medicaid beneficiary, the provider’s sole course of remedy shall be the MCO; a provider shall not seek payment from or institute litigation against a beneficiary.) See also 42 C.F.R. § 447.20 (a provider furnishing services to an individual may not seek to collect from the individual any payment for the amount of that service); 42 C.F.R. § 447.15 (health care providers participating in state Medicaid and Medicare programs agree to accept payments under those programs as payment in full). See also 42 U.S.C. § 1396(a) (25) (c) (state plan may not allow health care providers to seek payment for services from the beneficiary or the
beneficiary’s relatives). Both New Jersey and Federal regulations prohibit providers from billing Medical Assistance recipients for any covered medical services and must accept payment by the Plan as payment in full for covered services rendered under the Plan. Federal and State Medicaid regulations explicitly prohibit these billing practices unless certain notifications and procedures are met.
Physicians and other health care providers are encouraged to instruct their office staff to ask for appropriate documentation of a patient's insurance coverage and accurately maintain this information in all their billing systems. If your office has not received payment for covered services provided to an
AmeriChoice member, call 1-888-DOC-DENT (1-888-362-3368)
Articles of Importance
to Read:
Page 1
• What You Need to Know About Balance Billing
Page 2
• Human Papillomavirus (HPV) Update
• National Healthy First Steps Program
Page 3
• Provider Alert: February 2010s
Page 6
• Prior Authorization Required for Enterals, Parenterals and Children’s Formulas
Page 8
• Dual-Eligible Special Needs Plans Important Information for Providers
Page 9
• URGENT NATIONAL PROVIDER IDENTIFIER INFORMATION
Page 10
• Update
Health Net transition to NJ AmeriChoice
Spring 2010
Important information for physicians and other health care professionals and facilities serving AmeriChoice members
Human Papillomavirus (HPV) Update
GARDASIL [HUMAN PapillomavirusQuadrivalent (Types 6, 11, 16 and 18) Vaccine, Recombinant] is the only cervical cancer vaccine that helps prevent against 4 types of HPV: 2 types that cause 70% of cervical cancer cases, and 2 more types that cause 90% of genital warts cases. GARDASIL is for girls and young women ages 9 to 26.
The good news is that GARDASIL is a covered benefit for AmeriChoice members. For
members under 19 years of age, it is covered under the Vaccine for Children Program and those 19 years and older under their
immunization benefit. Providers should use the CPT code 90649 when submitting for reimbursement for the GARDASIL vaccine. GARDASIL may not fully protect everyone, and does not prevent all types of cervical cancer. GARDASIL does not treat cervical cancer or genital warts. It is important to stress to your patients the importance of continued routine cervical cancer screenings even if they have had GARDASIL.
You may access information regarding the HPV vaccine at the Centers for Disease Control and Prevention web site at:
http://www.cdc.gov/vaccinesafety/Vaccines/HP V/Index.html
National Healthy First Steps Program
AmeriChoice is pleased to announce the implementation of an enhanced national model of care for Maternal and Neonatal Intensive Care Unit (NICU) management. Healthy First StepsTM(HFS) is a AmeriChoiceprogram that has proven its efficacy over the
years. Now, by leveraging best practices across our organization, we expect to improve prenatal, postpartum and newborn care. Important: Many of you will realize no material changes to the HFS program, processes or technology. However, others will benefit from the availability of enhanced obstetrical care management services that include behavioral health and social work components. Please continue to submit OB referrals, but note that these should now be submitted into the HFS program via the new numbers identified in this document below.
The Healthy First Steps model of care encompasses two components: Maternal Care and NICU.
HFS-Maternal Care Model
The objective of the HFS-Maternal care model is to create a structure that consistently: • Increases early identification and
enrollment of expectant mothers
• Assesses the risk level of each member and directs them to proper care
• Increases the member's understanding of pregnancy and newborn care
• Encourages pregnancy and lifestyle self-management
• Encourages appropriate pregnancy, postpartum and infant provider visits • Fosters a physician-member partnership for
care in non-emergent settings HFS-NICU Model
The HFS-NICU care model will bring forward: • Telephonic and on-site case management
• Utilization management, including quality management and improvement activities such as participating in action planning or quality measurement activities
• Engagement of caregiver/family to promote empowerment and provide educational materials
• Facilitation of discharge planning needs by coordinating with the hospital and families • Reduction of hospital workload by
leveraging resource efficiencies (Nurses will seek to collaborate and support current staff)
We now have a dedicated team that will be providing NICU onsite and telephonic case management services. This team will focus specifically on promoting continuity of service and care, encouraging family involvement, and assisting with the neonate’s successful transfer home by coordinating discharge planning needs. We expect this increased support to improve NICU member outcomes and to grow your satisfaction with us as your partner in delivering care to our NICU
members. NRS will support your hospital’s NICU staff and neonatologists in their role as clinical decision-makers and optimize family involvement in the baby’s care.
Access to Providers in Key Specialties Medical support for the Healthy First Steps Model will be provided by physicians who are Board Certified in Maternal and Neonatal Medicine. These physicians will be providing clinical supervision and education to our staff as well as conducting peer to peer
discussions with providers. The HFS program will be responsible for ensuring that members receive the services and education they need
at the right time, in the right place and according to specific member needs. We will continue to send you more detailed communications as the HFS National Model implementation occurs in your area. We look forward to the opportunity to partner with you in a continued effort to improve pregnancy and newborn outcomes.
Please note these NEW Provider OB
Referral Numbers
Phone: 1-800-599-5985
Fax: 1-877-353-6913
Provider Alert: February 2010
1. Provider Complaints or GrievancesIf you have a complaint or grievance, you may call the Provider Service Center at 1-888-362-3368 and speak to a Customer Center Professional (CCP). Hours of
operation are 8 A.M. to 6 P.M. EST, Monday through Friday. If we are not able to resolve your inquiry during the initial call, a written response will be sent to you within thirty (30) days of your call.
If you have a provider complaint related to a payment issue, you will be advised to follow the procedure for “Provider Claim Payment Appeal” process outlined below, which does not require any action by an AmeriChoice member. If you have already submitted the payment appeal and are not aware of the status, the CCP can provide you with the status of the appeal. You may also utilize the Provider Portal to review the status of a claim/payment appeal if the claim was originally submitted
2. Provider Claim Payment Appeal Processes Claim payment disputes are disputes that do not require any action by the
AmeriChoice member. The claim payment appeal process is a procedure to resolve billing, payment, and other administrative disputes between the health care provider and AmeriChoice for any reason including, but not limited to: lost or incomplete claim forms or electronic submissions; requests for additional explanation as to services or treatment rendered by a health care provider; inappropriate or unapproved services initiated by the providers; or any other reason for billing disputes. There are two types of claim payment appeals: Informal and Formal.
A. Informal Claim Appeals
Informal claim payment appeals are claim resubmissions in order to revise a previously submitted claim and obtain payment. Claim disputes can be handled through this process if additional
administrative information is submitted for payment such as proof of timely filing.
If you are disputing a claim that was denied because filing was not timely, please include the following:
! • Electronic claims – include
confirmation that AmeriChoice or one of its affiliates received and accepted your claim.
• Paper claims – include a copy of a screen print from your accounting software to show the date you submitted the claim.
Requests for informal claim payment appeals must be submitted within ninety (90) days from the receipt of the EOB/PRA. They can be submitted online at
www.americhoice.com, by calling the Provider Service Center at 1-888-362-3368, or in writing to the following address: AmeriChoice of New Jersey
Attention: Claim Administrative Appeals P.O. Box 5250
Kingston, NY 12402-5250
Please note that clinical information will not be reviewed for appeals based on medical necessity, experimental or investigational services through the informal claim payment appeal process.
If you are dissatisfied with the claim payment appeal outcome and would like to submit a formal claim payment appeal, the formal appeal must be done within ninety (90) days of the original date of denial on your EOB/PRA on a Health Care Provider Application to Appeal a Claims Determination (HCAPPA) form. Please be advised that you do not receive an additional ninety (90) days from the date of the decision of the informal claim payment appeal.
B. Formal Claim Appeals
Formal claim payment appeals must be submitted to AmeriChoice utilizing the Department of Banking and Insurance approved form, Health Care Provider Application to Appeal a Claims
Determination (HCAPPA) which is located on the AmeriChoice.com website. If you submit a claim payment appeal using this form within 90 days following receipt of the EOB/PRA,you will have the right to
access the New Jersey Department of Banking and Insurance arbitration process in the event that you are not satisfied with the decision made by AmeriChoice. If you are not satisfied with the appeal decision made by AmeriChoice, and filed your initial appeal utilizing the Health Care Provider Application to Appeal a Claims Determination (HCAPPA) form, you may initiate the New Jersey Department of Banking and Insurance arbitration process by writing to the address shown below on or before the 90th calendar day following the receipt of the claim payment
determination. Attn: NJPICPA MAXIMUS
50 Square Drive, Suite 210 Victor, NY 14564
Providers can also access and submit the request online at:
http://www.njpicpa.maximus.com 3. Provider Service Appeals
Claim appeals based on AmeriChoice’s adverse determination regarding medical necessity, experimental or investigational services should be processed under the Utilization Management (UM) appeal process within 60 days from receipt of the original UM denial letter.
According to New Jersey Administrative Code 11:24-8.4, any provider appealing on behalf of a member must have the
member’s written consentin order to request a Utilization Management (UM) appeal. To proceed with a Stage 1 Utilization Management Appeal, include a copy of the original UM denial letter, the member’s written consent, a copy of the
medical record, and any additional information which supports the need for medical necessity on the denied date (s) of services.
Utilization Management Appeals should be mailed to the following address:
AmeriChoice of New Jersey
Attention: UM Appeals Coordinator P.O. Box 31364
Salt Lake City, UT 84131
To ensure all required medical information is reviewed with your appeal, it is
important to send the necessary medical records with the initial appeal request. The appeal process will start in the absence of necessary medical records.
Note: If a provider submits a UM appeal on behalf of a member with clinical
information and without member written consent, the appeal will be considered a provider service appeal. Although clinical information may be reviewed for medical necessity, the provider appealing on behalf of a member is not entitled to a Stage II UM appeal nor the New Jersey
Department of Banking and Insurance arbitration process.
3. Provider Central Service Unit (PCSU) To improve our business interactions with our providers, AmeriChoice of New Jersey, Inc (AmeriChoice) offers providers’ access to our Provider Central Service Unit (PCSU). The focus of the PCSU is to resolve claims payment issues for AmeriChoice NJ FamilyCare/Medicaid members that have not been resolved to your satisfaction onlyafter utilizing standard avenues of resolution.
Before contacting the PCSU, AmeriChoice would like to remind you that the following resources should be utilized if you’ve submitted a claim and received either a payment or a denial for payment that you do not agree with:
• Visit our secure website for physicians and other health care professionals at www.americhoice.com. This is your best source for checking member eligibility information, claim status, and filing claim adjustment requests. • Many of the same transactions can also
be completed by calling our toll free provider service line at 888-362-3368. If you call about a claim issue, be sure to have the supporting documentation needed for prompt resolution.
If you disagree with our determination after using the on-line tools or calling our service center, an additional review may be requested by contacting the PCSU at 1-800-718-5360. The PCSU staff has a special team dedicated to address NJ FamilyCare/Medicaid claims issues.
Prior Authorization Required for
Enterals, Parenterals and Children’s
Formulas
Effective April 1, 2010prior authorization will be required for all enterals, parenterals and children’s formulas. Note that for those enterals/formulas covered under New Jersey WIC (Women, Infants and Children), prior authorization will not be given. Therefore, providers should direct members to their local WIC agency to obtain these enterals /
formulas.
New Jersey WIC Services provides
supplemental nutritious foods to pregnant, breastfeeding and postpartum women, infants and children up to the age of five. WIC
services include nutrition education and counseling, breastfeeding promotion and support, immunization screening and health care referrals. NJ WIC’s web site contains valuable information and education tools for you and your patients. Please visit WIC at http://www.nj.gov/health/fhs/wic/index.shtml AmeriChoice prior authorization may be done via iExchange or by faxing your prior authorization request to 1-800-766-2597. You may also call the automated system at 1-888-362-3368. Please have your NPI and Tax ID numbers or the Member ID ready, or, you may hold to speak to a representative. The grid below outlines the formulas that are provided through WIC as of the date of this letter. Please follow up with WIC for ongoing updates.
New Jersey WIC Services
Authorized Exempt Infant Formulas and Medical Foods
These formulas must be approved by the State WIC office before issuance:
Local Agency CPA’s must approve these formulas with medical documentation
Neosure Advance (12.8 oz) and RTF (32 oz)*
Enfamil Enfacare Lipil (12.8 oz)* Alimentum Advance Similac Special Care Advance with Iron 24
Neocate Enfamil Nutramigen Lipil
Pediatric E028
Neocate Junior Enfamil Pregestimil Lipil(Formerly Pregestimil) Resorce 1.5 Calorie
Resorce 1.5 Calorie with fiber Nutren Junior Elecare
Peptamen Junior
Bright Beginnings Soy Drink (8 oz)
Pediasure
Pediasure with Fiber Phenyl-Free 1
Phenyl-Free 2 EnsureEnsure Healthy Mom
BCAD 1 & BCAD 2
(Replaces MSUD diet Powder) Ensure Plus RCF
Vivonex Pediatric Kindercal
Vivonex T.E.N.
Portagen Boost
Similac PM 60/40
Cyclinex-2 Boost High Protein
Tolerex
Product 3232A
PFD1 and PFD 2 Powder (Replaces Product 89956) Tyros 1 and Tyros 2 Powder (Replaces Product 3200 AB)
* These formulas may be approved by the local agency for premature infants up to eight pounds with medical documentation. Local agencies should call the State office for approval when premature infants are greater than eight pounds and/or for technical assistance. Revised 8/22/06
Dual-Eligible Special Needs Plans
Important Information for Providers
Under the Medicare Modernization Act of 2003 (MMA), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. Special needs plans (SNPs) were allowed to focus enrollment to one or more types of special needs individuals identified by Congress as: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions.The SNP plans maintain and monitor a network of participating providers including physicians, hospitals, skilled nursing facilities, ancillary providers and other health care providers through which Members obtain covered services.
Key points about coordination of carefor SNP Members include:
• SNP Members are encouraged to choose a Primary Care Physician (PCP) to coordinate their care. If a PCP is not chosen, the selection will be made for the member. • The SNP works with contracted PCPs who
manage the health care needs of SNP members and arrange for medically necessary covered medical services, including prior authorizations as necessary. • PCPs may, at any time, advocate on behalf
of the member without restriction in order to ensure the best care possible for the member.
• To ensure continuity of care, Members are encouraged to coordinate with their PCP before seeking care from a specialist, except in the case of specified services
(such as women’s routine preventive health services, routine dental, routine vision, and behavioral health).
• Contracted providers are required to coordinate member care within the SNP provider network. If possible, all SNP member referrals should be directed to the SNP contracted providers.
• Referrals outside of the network are
permitted, but only with prior authorization from the SNP.
Key points related to billing for servicesfor SNP Members include:
Full-benefit dual eligible members and Qualified Medicare Beneficiaries (QMBs) are not responsible for Medicare cost-sharing under Title XIX of the Social Security Act. You must not charge these dual eligible members for cost-share or balance bill them for any part of the unpaid charges. Rather, you may bill AmeriChoice and then submit the secondary claim to the member's Medicaid coverage provider. For these individuals, the payment from AmeriChoice as well as any payment received from the Medicaid coverage provider should be considered payment in full.
For services that are reimbursed by both Medicare and Medicaid for dual-eligible members, such as physician’s services for which Medicaid pays the Medicare
copayment, you are required to do one of the following:
• Accept both Medicare and Medicaid payment and do not bill patient more than any copayment required by the state, or
• If only accepting Medicare, do not balance-bill dual-eligible members for copayments paid by Medicaid
To learn about the full range of benefits and services for which members are eligible, your responsibility for cost-sharing (if any), and your right to reimbursement by both programs please contact 1-888-362-3368 or visit www.americhoice.com.
URGENT NATIONAL PROVIDER
IDENTIFIER INFORMATION
National Provider Identification (NPI)
As you know, Federal Regulations and many state Medicaid agencies require providers to submit a claim with their unique national provider identifier (NPI) on all electronic and paper submissions.
Clean Claim Billing Requirements
In addition to including your NPI, you must continue to submit complete claims to comply with AmeriChoice’s clean claim billing requirements as published in the Administrative Guide. In addition to all of the information that AmeriChoice expects to see when receiving a clean claim, it is mandatory that the claim include the following
information:
• Servicing address with zip code • Tax Identifi cation Number (TIN)
Failure to comply with all of AmeriChoice’s clean claim requirements as set forth in the Administrative Guide may result in the denial/rejection of the claim. If you have
not yet applied for and received your NPI, please do so immediatelyby visiting
https://nppes.cms.hhs.gov/NPPES/ or you can call the NPI Enumerator call center to request a paper application at 1-800-465-3203.
If you have not yet provided your NPI to AmeriChoice or any of the AmeriChoice government programs’ health plans, please do so immediately by going to your state specific physician site on www.americhoice.com, then choose the National Provider
Identifier Submission Information link under the Bulletins section.
For your convenience, there are
downloadable forms on the website for you to fill in the appropriate information. NPI information, provider name, TIN, and address can also be faxed to 1-866-943-0517, e-mailed to americhoice_dbm_npi@uhc.com, or mailed to:
AmeriChoice DBM Claims P.O. Box 16900
Update
Health Net transition to NJ
AmeriChoice
On December 11, 2009, UnitedHealthcare completed the acquisition of Health Net of the Northeast’s licensed subsidiaries, which includes Health Net of New Jersey, Inc. Effective May 1, 2010, Health Net of New Jersey, Inc.’s Healthy Options (NJ
FamilyCare/Medicaid) membership will transition to either the AmeriChoice of New Jersey (AmeriChoice) health plan, or another participating NJ FamilyCare/Medicaid
program health carrier selected by the transitioning Health Net member.
For more information and updates as they happen, please visit www.americhoice.com. If you have questions that cannot be
answered via the web, please call your Provider Services Center at (888) 362-3368
1 River Front Plaza P.O. Box 200089 Newark, NJ 07102-0304
Practice Matters is a periodic publication for physicians and other health care professionals and facilities in the AmeriChoice network.