AmeriHealth PPO HSA-qualifi ed High Deductible Health Plans

Transcription

P A
R T
N
in
E
R
S
Health
U P D AT E
W O R K I N G
T O G E T H E R
F O R
Q U A L I T Y
H E A LT H C A R E
www.amerihealth.com
INSIDE THIS ISSUE: JANUARY 2006
ANNOUNCEMENTS
• AmeriHealth PPO and CMM Conversion Finalization
• Claims Preprocessor Enhancements Effective March 2006
• Pregnancy Depression Screening
• No Referrals Required for Small Employer Health (SEH) HMO Plus and POS Plus Plans (NJ only)
NEW PRODUCTS
• AmeriHealth New Jersey Introduces HMO Plus
• New Product Effective January 1, 2006: Amerihealth 65® Plus (Open Access POS) (NJ only)
• AmeriHealth Introduces AmeriHealth PPO HSA-qualified High Deductible Health Plan
Effective January 1, 2006 (DE only)
PHARMACY ANNOUNCEMENTS
• Select Drug Program® Formulary Changes
CLASS ACTION SETTLEMENT UPDATE
• Settlement Recap
• Assistant Surgery Modifiers -80, -81, -82
• Co-Surgery Modifier -62
NAVINETSM ANNOUNCEMENTS
• Tips for Submitting Electronic Referrals
REMINDER
• ICD-9-CM Diagnosis Codes Change for Routine Gynecological Exams
FOR YOUR PATIENT’S HEALTH
• Supporting Our Members, Your Patients: ConnectionsSM Health Management Programs
ANNOUNCEMENTS
AmeriHealth PPO and CMM Conversion Finalization
U P D A T E
For the final phase of converting AmeriHealth PPO
and CMM claims processing to our new managed care
information system, AmeriHealth will discontinue
processing PPO and CMM claims and adjustments on
its former adjudication system on March 31, 2006.
By February 15, 2006, providers must submit all
claims and adjustment requests for dates of service
October 31, 2004 and earlier for consideration on
the former system. Please note that timely filing
requirements will be applicable to all clean claims.
For timely filing requirements, please reference the
letter dated May 1, 2005.
For New Jersey AmeriHealth PPO and
CMM Members
For Delaware AmeriHealth PPO and CMM Members
Electronic Billers should continue to use NAIC code
54704 in ISA-08 and NAIC code 93688 in GS-03.
Electronic Billers using Emdeon (formerly WebMD)
should continue to use Payer ID SX074 in GS-03 for
submission of AmeriHealth PPO and CMM claims.
Paper claims submissions should continue to be
submitted to the following address:
AmeriHealth Processing Center
P.O. Box 41574
Philadelphia, PA 19101-1574
If you have any questions, please contact your Network
Coordinator or Provider Services.
Electronic Billers should continue to use NAIC code
54704 in ISA-08 and NAIC code 60061 in GS-03.
Electronic Billers using Emdeon (formerly WebMD)
should continue to use Payer ID SX075 in GS-03 for
submission of AmeriHealth PPO and
CMM claims.
Claims Preprocessor Enhancements
Effective March 2006
January 2006
Tentatively Scheduled for March 20, 2006, in order
to streamline our pre-adjudication editing process for
electronic and paper claims, AmeriHealth is pursuing
an initiative that will consolidate these edits on to
one platform. The Electronic Data Interchange (EDI)
Claims Preprocessor will begin performing these
pre-adjudication edits for the AmeriHealth New Jersey
POS/PPO/Traditional Medical/Preferred Provider
Network and AmeriHealth Delaware POS/PPO/CMM
electronic and paper submissions.
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Q. How will this change affect professional provider
submissions?
A. Providers should continue to submit claims according
to the AmeriHealth guidelines.
Q. How will professional provider claims be validated?
A. Provider claims will continue to be validated against
the existing AmeriHealth business rules.
Electronic claims submitters will continue to receive the
Unsolicited 277 notification of both rejected and accepted
claims, a quick and efficient means to correct and resend
files to ensure an expedited remittance. Paper claims
submitters will continue to receive the rejected claim
report. If you are using a clearinghouse and are not
receiving the U277 reports for electronic claims, please
contact your vendor. If you are a paper submitter and
are not receiving a rejected claim report, please contact
the eBusiness help desk at (215) 241-2305 or via e-mail
at claims.edi-admin@amerihealth.com.
Updated information on the enhancement will be
available in a future edition of Partners in Health Update.
You may also reference:
www.amerihealth.com/providers/self_service _tools
or contact your Network Coordinator.
www.amerihealth.com
In September 2005, Baby FootSteps® instituted
a targeted screening program which is to screen
pregnant women for depression using the Whooley
Questionnaire, a two-question depression screening tool.
Outreach calls are currently administered by Baby
FootSteps® to women in their 28th week of pregnancy.
The following two screening questions have been added
to the 28 week questionnaire:
• During the past month, have you often been bothered
by feeling down, depressed, or hopeless?
If you have any questions, please call Baby FootSteps® at
(800) 598-BABY.
Source:
Whooley MA, Avins AL, Miranda J, Browner WS. Case Finding
Instruments for Depression: Two Questions as Good as Many. J Gen
Intern Med 1997; 12: 439-45
January 2006
• During the past month, have you often been bothered
by little interest or pleasure in doing things?
A positive answer to both screening questions indicates
a need for an evaluation for depression and possible
mental health referral. Therefore, when possible, Baby
FootSteps® offers a mental health referral to those
women who answer yes to both questions. Your office
may be receiving calls regarding those members who
screen positively.
U P D A T E
Pregnancy Depression Screening
www.amerihealth.com
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NEW PRODUCTS
U P D A T E
AmeriHealth New Jersey Introduces
51+ HMO Plus (NJ only)
AmeriHealth HMO Inc., in New Jersey introduced
AmeriHealth 51+ HMO Plus, a new HMO benefit
program for New Jersey large group employers, effective
December 1, 2005.
AmeriHealth 51+ HMO Plus requires members to
select a PCP who is available to provide primary and
preventive care services. PCP reimbursement for these
members will be made on a fee-for-service basis and
members will be identified separately on your monthly
capitation/eligibility roster.
AmeriHealth HMO Plus members can be easily
identified by the HMO Plus and “No Referrals
Required” indicators on their ID cards.
Please refer to the enclosed product booklet for further
details on this benefit program. It should be filed in the
Products section of your Provider Manual.
Please contact Provider Services or your Network
Coordinator with any questions about the AmeriHealth
HMO Plus benefit program.
AmeriHealth HMO Plus members are exempt from all
referral requirements. Members may access care from
any participating provider without a referral from their
PCP and receive the highest level of coverage.
New Product Effective January 1, 2006:
AmeriHealth 65® Plus (Open Access POS) (NJ only)
Effective January 1, 2006, AmeriHealth 65® will be
introducing AmeriHealth 65 Plus, an open access POS
product in New Jersey.
Please contact Provider Services with questions
regarding these new products.
January 2006
AmeriHealth 65 Plus will be available statewide
to employer health groups, as well as to Medicareeligible individuals residing in Burlington, Camden,
Cumberland, Gloucester, and Salem counties beginning
January 1, 2006. AmeriHealth 65 Plus requires members
to choose a PCP in the AmeriHealth 65 network;
however, members can access care in- or out-of-network
without a referral. Members utilizing in-network
providers will receive the highest level of benefit. The
PCP copay will apply when the member visits any
network PCP.
The enclosed product booklet contains copayment,
prior authorizarion, and information applicable to the
AmeriHealth 65 Plus product. Please file the enclosed
product booklet in the Products section of your
Provider Manual.
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www.amerihealth.com
AmeriHealth Introduces AmeriHealth PPO
HSA-qualified High Deductible Health Plan
Effective January 1, 2006 (DE only)
Identification Cards
On the member’s AmeriHealth PPO identification
card (ID), you will see a line of text that identifies the
AmeriHealth PPO HSA-qualified High Deductible
Health Plan (HDHP) option in which the member
is enrolled. For example, an ID card that reads
HDHP–HD1-HC1 indicates that a member is enrolled
in a program that includes a $1,500 deductible for single
contracts and a $3,000 deductible for a family contract
(HD1). HC1 indicates that the member’s plan is an 80%
network coinsurance plan—AmeriHealth pays 80% of
Plan allowance after the deductible is met for most
eligible services.
Family Aggregate Deductible
A new feature of these plans is the family aggregate
deductible: The family deductible and out-of-pocket
maximum apply when an individual and one or more
dependents are enrolled. The entire family deductible
must be met before benefits are paid. The single
deductible and out-of-pocket maximum apply when an
individual is enrolled without dependents.
All injectables that are shown on the Biotech/Specialty
Injectables list must be obtained through the Direct Ship
Program. Injectables are subject to applicable deductible
and coinsurance and apply to AmeriHealth PPO
HSA-qualified High Deductible Health Plan members.
Please note: Biotech/Specialty Injectables that are provided
in the physician’s office from a physician’s supply are also
subject to applicable Pharmacy Services precertification
requirements prior to the administration of any Biotech/
Specialty Injectable. Precertification is required for the
listed Biotech/Specialty Injectables and is facilitated via the
Direct Ship process.
Standard office-based injectables, such as antibiotics and
steroids, are also subject to the applicable deductible and
coinsurance.
U P D A T E
Please see below for important information about the
new health plans.
Biotech/Specialty Injectables
Note: Please remember to reference the updated
Biotech/Specialty Injectables list, effective January 1,
2006, when ordering Biotech/Specialty injectables for
Health Plan members. The latest version of the list
can be found as an enclosure in the November issue of
Partners in Health Update.
Precertification Requirements
Precertification requirements for AmeriHealth PPO
HSA-qualified High Deductible Health Plans are
consistent with precertification requirements for the
Flex Copay Series programs.
When applicable, member copays may be collected at
time of service (i.e., preventive office visits and routine
gynecological exams). For all other services, to ensure
that members are billed correctly, claims should be
adjudicated by AmeriHealth before the member is
billed.
Please file the enclosed product booklet in the Products
section of your Provider Manual.
www.amerihealth.com
January 2006
AmeriHealth is pleased to announce that new
Health Plans will be available to employer groups
effective January 1, 2006. These plans are designed to be
paired with a Health Savings Account (HSA). There will
be four standard deductible options and two coinsurance
options that can be combined into a total of eight
different product offerings. Single network deductible
options range from $1,500 to $3,000. Standard
coinsurance options include a 0% coinsurance
option—in which AmeriHealth pays 100%
in-network after the deductible is met—as well as
an 80% coinsurance option.
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PHARMACY ANNOUNCEMENTS
U P D A T E
Select Drug Program® Formulary Changes
The Select Drug Program® Formulary is a list of
FDA-approved medications that were chosen for their
effectiveness and value. The list changes periodically
as AmeriHealth reviews the formulary to ensure
its continued effectiveness. Please see below for
information on brand additions and deletions, generic
additions, and drugs with prior authorizations.
In addition, you can view the Select Drug Program®
Formulary as well as all drugs with prior authorizations
at www.amerihealth.com/provider_rx.
Brand Addition
This Drug is Covered at the Appropriate Brand Formulary Copayment
Effective Immediately
Brand Drug
PhosLo®
Formulary Chapter
16. Diagnostic and Miscellaneous Agents
Once a brand drug is approved by AmeriHealth’s
Pharmacy and Therapeutics (P&T) Committee, it will
be immediately added to the formulary and will be
available at the brand formulary copayment.
The brand drug listed above has been added since the
last printing of the Select Drug Program® Formulary.
Brand Deletions
These Drugs are Covered at the Appropriate Non-Formulary Copayment+
Effective March 1, 2006
Brand Drug
Brovex-D® suspension 12-20*
Miacalcin® Spray*
Generic Drug
brompheniramine/phenylepherine
calcitonin nasal spray
* The generic equivalents for all of these brand drugs are on our formulary and are available at the generic formulary copayment. Members may
contact their doctor to discuss formulary alternatives.
+
Non-formulary injectables are not covered.
Drugs with Prior Authorization
Effective March 1, 2006 For Medicare Part D Members
Effective Immediately for Commercial Members
January 2006
The following formulary drugs have been added to the list of drugs requiring Prior Authorization for new
prescriptions:
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Brand Name
Ambien-CRTM
LunestaTM
Lyrica®
Rozerem®
Generic Name
zolpidem
eszoplicone
pregabalin
ramelteon
www.amerihealth.com
Generic Additions
These Drugs are Covered at the Appropriate Generic Formulary Copayment
Effective Immediately
Aclovate cream
Formulary Chapter
5. Dermatologicals/Topical Therapy
®
benzoyl peroxide/urea cream
Zoderm 6.5% cream
car-b-pen ta/phenylephrine/BPM
Betatan® suspension
13. Allergy, Cough & Cold, Lung Meds
car-b-pen ta/phenylephrine
levall-12® suspension 30-30mg
carbinoxamine maleate liquid
Pediatex® liquid
clonazepam wafer tablet
Klonopin® wafer tablet
3. Autonomic & CNS drugs, Neurology
& Psych
dextromethorphan tannate/
pseudoephedrine tannate/
carbinoxamine
Pediatex 12 DM® suspension
dicyclomine syrup
Bentyl® syrup 10mg/5ml
8. Gastroenterology
fexofenadine
®
Allegra
®
guaifenesin/phenylephrine/
hydrocodone
Duratuss HD elixir
hydrocortisone butyrate 0.1% cream
Locoid® 0.1% cream
hydrocodone/guaifenesin tab
Pneumotussin® tab 2.5-300mg
iron, carbonyl 15mg
Icar® chewable 15 mg
15.Vitamins & Electrolytes
®
methenamine/methylene blue/
benzoic acid/ salicylic acid/atropine/
hyoscyamine
Prosed EC tab
phenylephrine/hydrocodone/BPM
Flutuss HC® liquid
phenylephrine/hydrocodone/CP
Maxituss HC® syrup
phenylephrine/hydrocodone/
diphenhydramine syrup
Tussinate® syrup
phenylephrine/hydrocodone/
chlorpheniramine
Z-cof HC® liquid
pseudoephedrine hcl/
carbinoxamine mal
Pediatex D® liquid
pseudoephedrine hcl/hydrocodone/CP
Pediatex HC® liquid
pseudoephedrine w/hydrocodone
syrup 15-3 mg/ml
Pancof HC® syrup
dextromethorphan hbr/
pseudoephedrine hcl/carbinoxamine
Pediatex DM® liquid
sodium fluoride solution rinse
Prevident® solution rinse
16. Diagnostics & Miscellaneous agents
14. Urologicals
®
sulfacetamide sodium 10% lotion
Sebizon 10% lotion
sulfacetamide sodium/urea lotion
Carmol® scalp lotion
urea cream
®
Keralac cream
Once a generic product becomes available upon
approval of the FDA and the carrier, it will be added
to the formulary and will be available at the generic
U P D A T E
aclometasone cream
Brand Drug
®
formulary copayment. The generic drugs listed above
have been added since the last printing of the Select
Drug Program® formulary.
www.amerihealth.com
January 2006
Generic Drug
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CLASS ACTION SETTLEMENT UPDATE
Settlement Recap
The class action settlements involving New Jersey and Delaware providers [of Gregg, et al. v. Independence Blue
Cross, et al., Good v. Independence Blue Cross, et al., and Pennsylvania Orthopaedic Society v. Independence
Blue Cross, et al.] include the following enhancements for providers who agreed to the settlement:
• Improving disclosure to Settlement Providers, including standard fee schedules, changes to schedules, and
medical and payment policies that may affect payment/reimbursement of services, which will be made available
online via NaviNetSM, our secure provider portal.
• Changing claims processing for Settlement Providers on the following: selected modifiers (-25, -50, -51, -59,
-62, -66, -80, -81, -82, -RT, -LT), multiple surgical procedures, radiological guidance during a procedure, and
certain Current Procedural Terminology (CPT)** code-level designations (e.g., Modifier -51 exempt, Separate
Procedure, Add-on codes).
• Introducing a two-level, formal claims appeal process for Settlement Providers in AmeriHealth’s Delaware
subsidiary. AmeriHealth New Jersey providers will continue to have access to the existing provider claims appeal
process.
Certain of these enhancements are currently available. Others will be announced as they become available.
* The following is a link to the Medicare website: www.cms.gov. These sites are maintained by organizations over which AmeriHealth exercises
no control, and accordingly, AmeriHealth expressly disclaims any responsibility for the content, the accuracy of the information, and/or quality
of the products or services provided by or advertised in these third-party sites. Certain services/treatments referred to in other sites may not be
covered under specific benefit plans. Please refer to benefit contracts for complete details of the terms, limitations, and exclusions of coverage.
** Current Procedural Terminology (CPT®) is a copyright of the American Medical Association (AMA). All Rights Reserved. No fee schedules,
basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable
FARS/DFARS restrictions apply to government use. CPT® is a trademark of the AMA.
January 2006
C L A S S
A C T I O N
S E T T L E M E N T U P D AT E
Enhancements to Claim Payment Policy, Processing and Payment Disclosure, and an Appeals Process for
Class Action Settlement Providers
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www.amerihealth.com
Assistant Surgery Modifiers -80, -81, -82
Assistant surgery modifiers -80, -81, and -82 are used to denote surgical procedures that require both a primary and
an assistant surgeon because of the complexity and/or time requirement of the surgery. An assistant surgeon is a
surgeon who actively assists and supports a primary surgeon during a surgical procedure. Both primary and assistant
surgeons should report the same procedure code. The assistant surgeon should append the most appropriate
assistant surgery modifier based on the narrative.
The table below identifies and describes the intended processing outcome associated with each indicator. However,
reimbursement consideration for services reported with modifiers -80, -81, and/or -82, are also contingent upon
eligibility, benefits, exclusions, precertification/referral requirements, provider contracts, and/or applicable policies.
Payment for these procedures is based on 20% of the fee schedule allowance for the surgical service. Please note
that assistant surgical services that are performed in conjunction with other surgical services may be subject to
multiple surgery reduction guidelines.
CMS utilizes a payment methodology for these types of services by applying assistant surgery payment indicators
to procedure codes that, when submitted in combination with modifiers -80, -81, and/or -82 will allow or restrict
payment consideration:
CMS Indicator & Description
(0) Assistant surgery payment is inappropriate unless
documentation supports medical necessity.
(1) Assistant surgery payment is inappropriate.
(2) Assistant surgery payment is appropriate.
(9) Concept does not apply.
Outcome for code/modifier -80, -81,
and/or -82 combination
Ineligible for assistant surgery; additional consideration
determined on an appeal basis only.
Ineligible for assistant surgery reimbursement
consideration.
Eligible for assistant surgery reimbursement
consideration.
Invalid procedure/modifier code combination.
January 2006
Medical records, operative reports, and/or other supporting documentation should not be appended to the claim or
submitted to the Company unless specifically requested by the Company.
C L A S S
A C T I O N
S E T T L E M E N T U P D AT E
AmeriHealth has enhanced its processing system to apply the Centers for Medicare & Medicaid Services (CMS)
payment methodology for modifiers that represent assistant surgery [Assistant Surgeon -80; Minimum Assistant
Surgeon -81; Assistant Surgeon (when qualified resident surgeon not available) -82] as outlined in the Medicare
Physician Fee Schedule Database on the CMS website.*
www.amerihealth.com
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CLASS ACTION SETTLEMENT UPDATE (continued)
Co-Surgery Modifier -62
U P D A T E
AmeriHealth has enhanced its processing system to apply the Centers for Medicare & Medicaid Services (CMS)
payment methodology for co-surgery modifier -62 as outlined in the Medicare Physician Fee Schedule Database on
the CMS website.*
Co-surgery modifier -62 is used to denote when two surgeons act as primary surgeons during the same operative
procedure or session for the same individual because of the complexity of the procedure and/or the patient’s
condition. The co-surgeons are typically of different specialties and perform consecutive or overlapping parts of
the same procedure or simultaneous procedures during the same session with one of the following exceptions for
co-surgeons of the same specialty:
• Each surgeon must perform a distinct part of the surgical procedure that requires the distinct skills of each surgeon.
• Each surgeon performs the same procedure(s) simultaneously for different regions/organs (e.g., bilateral lung
reduction, bilateral knee replacements). In such cases, the operative report must reflect the necessity of two primary
surgeons with the same skills.
Each of the two surgeons should submit the same procedure code that represents the entire surgical procedure
appended with modifier -62.
The table below identifies and describes the final processing outcome that is associated with each indicator; however,
reimbursement consideration for services reported with modifier -62 are also contingent upon eligibility, benefits,
exclusions, precertification/referral requirements, provider contracts, and applicable policies. Payment for these
procedures is based on 62.5% of the fee schedule allowance for the service. Please note that co-surgery services that
are performed in conjunction with other co-surgery services are subject to multiple surgery reduction guidelines.
CMS utilizes a payment methodology for these types of services by applying co-surgery payment indicators
to procedure codes that, when submitted in combination with modifier -62, will allow or restrict payment
consideration:
CMS Indicator & Description
(0) Co-surgery payment is inappropriate.
(1) Co-surgery payment is inappropriate unless
supporting documentation establishes medical
necessity.
(2) Co-surgery payment is appropriate.
(9) Concept does not apply.
Outcome for code/modifier -62
Ineligible for co-surgery reimbursement consideration.
Ineligible for co-surgery; additional consideration
determined on an appeal basis only.
Eligible for co-surgery reimbursement consideration.
Invalid procedure/modifier code combination.
It is inappropriate to report modifier -62 when one surgeon acts as an assistant to the primary surgeon or when
more than two surgeons act as primary surgeons during the same operative session.
January 2006
Medical records, operative reports, and/or other supporting documentation should not be appended to the claim
or submitted to the Company unless specifically requested by the Company.
10
www.amerihealth.com
NAVINETSM ANNOUNCEMENTS
Tips for Submitting Electronic Referrals
When using the Interactive Voice Response (IVR) Unit
to submit referrals, providers may back date the referrals
for members up to seven days. When prompted for the
date of service, enter a date not more than seven days
prior to the date of issue.
For additional information on this transaction, please
refer to the User Guides located in the Customer Service
drop-down menu, or contact NaviNetSM Customer
Care at (888) 482-8057.
REMINDERS
No Referrals Required for Small Employer Health (SEH)
HMO Plus and POS Plus Plans (NJ only)
Effective July 1, 2005, AmeriHealth introduced
two new group products in New Jersey. Information
pertaining to the new products and benefits appeared in
the July Partners in Health Update. Please see below for
important reminders about the new products and the no
referrals benefit:
AmeriHealth NJ Small Employer Health (SEH)
POS Plus:
AmeriHealth NJ Small Employer Health (SEH)
HMO Plus:
• Members are not limited to capitated networks for
radiology and physical therapy.
• Members must choose a PCP in the AmeriHealth
network.
• The PCP copayment will apply when the member
visits any network PCP.
• Members can access in-network specialist care without
a referral, as noted on the ID card.
Please note: The member identification cards for these
new products clearly state that no referrals are required.
This information can be found on the top portion of the
member ID card.
• Members are not limited to capitated networks for
radiology and physical therapy.
• Members must choose a PCP in the AmeriHealth
network.
• Members can access in-network OR out-of-network
specialist care without a referral.
Please contact Provider Services or your Network
Coordinator if you have questions regarding the no
referrals process.
January 2006
• The PCP copayment will apply when the member
visits any network PCP.
U P D A T E
When submitting referrals in NaviNetSM, the referrals
can be backdated by PCPs for up to seven days by
changing the referral date in the patient search screen.
Referrals that are backdated in the comments section of
the referral will not be accepted.
www.amerihealth.com
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REMINDERS (continued)
U P D A T E
ICD-9-CM Diagnosis Codes Change for
Routine Gynecological Exams
Effective January 1, 2006, capitated PCPs who bill for
routine gynecological exams should report diagnosis
code V72.31 with the applicable preventive evaluation
and management Current Procedural Terminology
(CPT)* codes 99384-99387 and 99394-99397 or
Healthcare Common Procedure Coding System
(HCPCS) codes S0610 and S0612 for reimbursement
consideration.
Routine gynecological exams that are reported with
ICD-9-CM code V72.32 for CPT codes 99384-99387
and 99394-99397 are no longer eligible for additional
payment outside the standard capitation amount.
HCPCS codes S0610 and S0612 may still be reported
with ICD-9-CM code V72.32 when appropriate.
Important reminder: As previously communicated,
effective October 1, 2004, we require all practitioners
to report diagnosis codes to the highest degree of
specificity, according to the ICD-9-CM Coding Manual.
If you have questions, please call Provider Services or
your Network Coordinator.
* Current Procedural Terminology (CPT®) is a copyright of the
American Medical Association (AMA). All Rights Reserved. No fee
schedules, basic units, relative values, or related listings are included
in CPT. The AMA assumes no liability for the data contained herein.
Applicable FARS/DFARS restrictions apply to government use.
CPT® is a trademark of the AMA.
For reference, the diagnosis code narratives are as
follows:
• V72.31: Routine gynecological examination.
January 2006
• V72.32: Encounter for Papanicolaou cervical smear to
confirm findings of a recent normal smear following
initial abnormal smear.
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FOR YOUR PATIENT’S HEALTH
Helping you and your patients manage five
chronic conditions (Asthma, CAD, CHF, COPD,
and Diabetes)
Promoting self-management and preventing
disease complications for patients with complex
chronic conditions
CONTACT THE CONNECTIONSSM HEALTH
MANAGEMENT PROGRAM PROVIDER
SUPPORT LINE AT (866) 866-4694 TO:
CONTACT THE CONNECTIONSSM
ACCORDANTCARETM PROGRAM AT
(866) 398-8761 TO:
1
2
3
4
5
Refer a member for Health Coaching.
Ask questions or provide feedback.
Request information regarding the SMARTTM
Registry.
Request ConnectionsSM posters for your
office, referral pads, and copies of
Clinical Insights.
Request individual patient information
for the purposes of treatment and care
coordination for your patient.
A ConnectionsSM Provider Service Specialist will
return your call within two business days.
U P D A T E
Supporting Our Members,Your Patients: ConnectionsSM Health Management Programs
1
Refer patients with the following complex
chronic conditions for disease management
support:
• Seizure Disorders
• Scleroderma
• Rheumatoid Arthritis
• Polymyositis
• Multiple Sclerosis
• Dermatomyositis
• Chronic Inflammatory
• Parkinson’s Disease
Demyelinating
• Systemic Lupus
Polyradiculoneuropathy
Erythematosus (SLE)
(CIDP)
• Myasthenia Gravis
• Amyotrophic Lateral
• Sickle Cell Disease
Sclerosis (ALS)
• Cystic Fibrosis
• Gaucher Disease
• Hemophilia
2 Ask questions and/or provide feedback.
3 Request an individual patient disease
management plan for the purposes of care
coordination for your patient.
Providing resources for you and your patients with end-stage renal disease
CONTACT THE CONNECTIONSSM KIDNEY PROGRAM AT (866) 303-4CKP [4257] TO:
Refer a member on chronic outpatient dialysis to a Health Service Coordinator.
Ask questions and/or provide feedback.
Request individual member information.
1
January 2006
1
2
3
www.amerihealth.com
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IMPORTANT RESOURCES
PROVIDER INFORMATION and
TOOLS WEB PAGE
PROVIDER SERVICES
Policies/Procedures/Claims
www.amerihealth.com/providers
PROVIDER MEDICAL POLICY
WEB PAGE
www.amerihealth.com/medpolicy
PROVIDER ELECTRONIC DATA
INTERCHANGE SERVICES
WEB PAGE
(866) 282-2707
(800) 275-2583
(800) 821-9412 NJ
(800) 888-8211 DE
Precertification
(800) 227-3116
PPO
CARE MANAGEMENT
AND COORDINATION
HMO Commercial
(800) 595-3627 NJ
(800) 888-8211 DE
PHARMACY SERVICES
Prescription Drug Authorization
(888) 671-5280
(888) 671-5285
CREDENTIALING COMPLIANCE
HOTLINE
Direct Ship Injectable
www.amerihealth.com/credentials
PROVIDER PHARMACY
WEBPAGE
www.amerihealth.com/provider_rx
eBUSINESS PROVIDER
INQUIRY LINE
(856) 638-2701 NJ
(302) 661-6111 DE
(800) 227-3116 NJ
(800) 373-4455 DE
PPO
(800) 373-4455
Toll-Free Fax
www.amerihealth.com/anti-fraud
(866) 282-2707
AmeriHealth Healthy LifestylesSM
HMO
www.amerihealth.com/edi
CORPORATE AND FINANCIAL
INVESTIGATIONS DEPARTMENT
Anti-Fraud and Corporate
Compliance Hotline
HEALTH RESOURCE CENTER
Case Management
(800) 313-8628 NJ
(800) 373-4455 DE
(267) 402-1711
(888) 671-5280
Baby FootSteps®
Fax
(215) 761-9165
CONNECTIONSSM HEALTH
MANAGEMENT PROGRAMS
PROVIDER SUPPORT LINE
Blood Glucose Meter Hotline
(866) 866-4694
(888) 494-8213 (option 2)
CONNECTIONSSM KIDNEY
PROGRAM
PROVIDER SUPPLY LINE
(800) 858-4728
The AmeriHealth Partners in Health
Monthly Update is a publication of the
Provider Communications department
for the exchange of information and
ideas among the AmeriHealth Provider
community. Suggestions are welcome.
Contact Information:
Rosemary Franks
Managing Editor
Elizabeth Derago
Production Coordinator
Provider Communications
AmeriHealth
1901 Market Street, 35th Floor
Philadelphia, PA 19103
Visit our website at www.amerihealth.com
(800) 598-BABY [2229]
(866) 303-4CKP [4257]
CONNECTIONSSM
ACCORDANTCARETM PROGRAM
(866) 398-8761
View our online provider directories at www.amerihealth.com.
AmeriHealth products are offered directly by QCC Insurance Company d/b/a AmeriHealth Insurance Company, AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey.
The third-party Web sites mentioned in this publication are maintained by organizations over which AmeriHealth exercises no control, and accordingly, AmeriHealth disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services
provided by or advertised in these third-party sites. URLs presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefit plans. Members should refer to their benefit contract for complete details of the terms,
limitations, and exclusions of their coverage.
Current Procedural Terminology (CPT®) is a copyright of the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.
Investors in NaviMedix®, Inc. include an affiliate of AmeriHealth, which has a minority ownership interest in NaviMedix®, Inc.
009189 2003-0269 07/05
ENCLOSURES
The following pages of this PDF include content that originally mailed with the
January edition of Partners in Health Update. These documents have been combined
into one PDF file on IBC’s website & Provider Manual CD for your convenience.
Copayment/Co-insurance Summary ...........................................................2
AmeriHealth 65 Plus Prior Authorization Requirements ...............................4
Product Overview
ID Cards
This booklet contains information regarding the
AmeriHealth 65® Plus (Open Access POS) product.
An AmeriHealth 65 Plus member will carry an
identification card that clearly indicates that the member
is enrolled in AmeriHealth 65 Plus. On the member’s
identification card, a line of text identifies the product and
the office copayment. These codes correlate to the benefit
options that are shown on the enclosed benefit guide.
AmeriHealth 65 Plus is available to New Jersey employer
group members statewide. AmeriHealth 65 Plus is also
available to Medicare eligible individuals residing in
Burlington, Camden, Cumberland, Gloucester, and Salem
counties. This product is effective January 1, 2006.
Sample AmeriHealth 65 Plus ID Card
AmeriHealth 65 Plus requires members to choose a
Primary Care Physician (PCP) from the AmeriHealth 65
network.
Referral Requirements
No referrals are required.
Prior Authorization
In-Network/Out-of-Network Services
• Services that are performed by providers who participate
in the AmeriHealth 65 network will process as in-network
services. Members utilizing in-network providers will
receive the highest level of benefit.
• Services that are performed by providers who do not
participate in the AmeriHealth 65 network will process
as out-of-network services. Members who utilize out-ofnetwork providers are responsible for an annual deductible
and coinsurance.
Prior authorization is not a determination of eligibility
or a guarantee of payment. Coverage and payment are
contingent upon, among other things, the member being
eligible (i.e., actively enrolled in the health benefits plan
when the prior authorization is issued and when approved
services occur). Coverage and payment are also subject
to limitations, exclusions, and other specific terms of the
health benefits plan that apply to the coverage request.
The prior authorization list is subject to change.
Provider Note
Please insert this booklet into the “Products” section of your
Provider Manual.
01/06
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AmeriHealth 65® Plus (Open Access) (NJ only)
AmeriHealth 65® Plus
(Open Access POS) (NJ only)
Copayment/Co-insurance Summary
AmeriHealth 65
AmeriHealth 65
Plus Medical Only Plus Rx Option II
Type of Service
Out-of-Network
Premium
$75
$107
(NA)
Deductible
None
None
$500
Coinsurance
None
None
70% of plan
allowance
$3,000
NA
$3,000
NA
$5,000
NA
Out-of-Pocket Maximum
Lifetime Maximum
Primary Care Office Visit
Urgent Care
Specialist Office Visit
OB-GYN Office Visit
Non-Routine Podiatry
Non-Routine Vision Exam
Physical and Occupational Therapy
Chiropractic (Spinal Manipulations)
Allergy Testing
Allergy Immunotherapy
Speech Therapy
Cardiac Rehab
Outpatient Laboratory/Pathology (outpatient facility & Lab)
Outpatient X-Ray/Radiology/Diagnostic Services Routine
Radiology/Diagnostic - one copay per date of service per
provider
$15
$15
70%
$15-$25
$25
$25
$25
$25
$25
$25
$0
$25
$25
$25
$0
$15-$25
$25
$25
$25
$25
$25
$25
$0
$25
$25
$25
$0
$15-$25
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
$25
$25
70%
- MRI/MRA, CT Scans/PET Scans (Preauthorization is required
for MRI/MRA, CT Scans/PET Scans)
$50
$50
70%
(No copay applicable when service is performed in an ER or
physician office setting.)
Outpatient Mental Health - unlimited
Outpatient Substance Abuse - unlimited
Routine Physical Examination
Routine GYN Exam/Pap
Routine Mammography
Prostate Cancer Screenings
Immunizations
Bone Mass Measurement Exam
Colorectal Screenings***
Routine Vision Exam
Diagnostic Hearing Exam
$25
$25
$0
$0
$0
$0
$0
$0
$0
$25
$25
$25
$25
$0
$0
$0
$0
$0
$0
$0
$25
$25
50%
70%
70%
70% no deductible
$0
70%
70%
70%
70%
70%
70%
* Biotech Injectable copayment of $25 for the following drugs: Lupron, Zoladex, and Trelstar.
** Urgent and emergency services received outside of the U.S. are covered at the out-of-network benefit level.
*** If a colonoscopy is performed in the Outpatient Surgery Unit of an acute care facility or Ambulatory Surgical Center, the Outpatient Surgery Facility copay applies.
+
There are two tiers of cost sharing, one for lower-cost (Tier 1) Hospitals, and another for higher-cost (Tier II) hospitals with the AmeriHealth hospital network. AmeriHealth 65 members will continue to have access to all
hospitals in the AmeriHealth network.
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Facility Ancillary
Inpatient Hospital+
AmeriHealth 65
Plus Medical Only
AmeriHealth 65
Plus Rx Option II
Tier 1
Tier 1
$100/day $500/stay $100/day $500/stay
Tier 2
Tier 2
$200/day $1,000/
$200/day $1,000/
stay
stay
Out-of-Network
70%
Tier 1 $75
Tier 2 $150
Tier 1 $75
Tier 2 $150
70%
$25/day
$25/day
70%
Home Health Care
$0
$0
70%
Hospice
$0
$0
70%
Inpatient Mental Health Facility 190 day lifetime maximum
$100/day/$500/
stay Separate Mental
Health Out-of-Pocket
cost share
$100/day/$500/
cost share
70%
Inpatient Substance Abuse 190 day lifetime maximum
$100/day/$500/
cost share
$100/day/$500/
cost share
70%
$0
$0
70%
Emergency Room - not waived if admitted**
$50
$50
$50
Ambulance
$50
$50
70%
Outpatient Surgery (per date of service)*+
Skilled Nursing Facility
(100 days per Medicare benefit period)
Inpatient Non-Hospital (Residential) Days 90 day lifetime maximum
Dialysis
Durable Medical Equipment
Diabetes Self-Monitoring Training and Supplies
Prosthetics
Certain Covered Injectables*
$0
$0
70%
20%
20%
50%
$0
$0
70%
20%
20%
50%
$25
$25
70%
AmeriHealth 65
Plus Medical Only
AmeriHealth 65
Plus Rx Option II
Out-of-Network
N/A
N/A
N/A
Actuarial Equivalent Part D
N/A
$5/$20/$40
Up to $1,800 (paid by
member and plan)
After member’s True
Out-Of-Pocket cost
(TrOOP) reaches
$3,600, members will
pay the greater of 5%
coinsurance or $2
generic and $5 brand
copay thereafter.
Member pays in full
and is reimbursed
entire amount minus
applicable copay of
$5/$20/$40
Enhanced Part D
N/A
N/A
N/A
Prescription Drug Benefit
Standard Part D
01/06
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AmeriHealth 65 Plus Prior Authorization Requirements
All services listed require prior authorization in-network and out-of-network (unless otherwise specified). It is the member’s
responsibility to obtain prior authorization for out-of-network services (see the Penalties section for more information).
Inpatient Services
Surgical/Non-Surgical Inpatient Admissions
Acute Rehab
Inpatient Hospice
Maternity Admission (for notification only)
Outpatient Facility/Office Services (other than Inpatient)
Infusion Therapy (except cancer chemotherapy, whole blood, and/or blood
plasma) in outpatient facility and office
Hysterectomy
Cataract Surgery
Nasal Surgery for Submucous Resection and/or Septoplasty
Dental Services as a result of accidental injury
Day Rehabilitation Programs
Transplants (except cornea)
Comprehensive Outpatient Pain
Management Programs (including epidural injections)
Obesity Surgery
Sleep Studies
Uvulopalatopharyngoplasty (including laser-assisted)
Radiological Services
MRI/MRA
CT/CTA Scan
Reconstructive Procedures and Potentially Cosmetic Procedures
PET Scan
Nuclear Cardiac Studies
Abdominoplasty
Augmentation Mammoplasty
Blepharoplasty
Chemical Peels
Dermabrasion
Excision of Redundant Skin
Keloid Removal
Lipectomy/Liposuction
Orthognathic Surgery Procedures
Mastopexy
Otoplasty
Panniculectomy
Reduction Mammoplasty
Removal or Reinsertion of Breast Implants
Rhinoplasty
Surgery for Varicose Veins
Scar Revision
Subcutaneous Mastectomy for Gynecomastia
All Home Care Services (including Infusion Therapy in the home)
Birthing Center (for notification only)
Elective (non-emergency) Ambulance Transport
Outpatient Private Duty Nursing
Prosthetics and Orthotics – Purchase items over $100, including repairs and replacements
Durable Medical Equipment – Purchase items over $100, including repairs and replacements, and ALL rentals (except
oxygen, diabetic supplies, and/or unit dose medication for nebulizer)
Biotech/Specialty Injectable Drugs
Psychiatric/Serious Mental Illness/Substance Abuse – Inpatient/Outpatient/Partial: In-network and out-of-network
In addition to the prior authorization requirements listed
above, prior authorization should be obtained for certain
categories of treatment so that the member will know prior
to receiving treatment whether it is a covered service. This
applies to network providers and members who elect to receive
treatment that is provided by out-of-network providers. The
categories of treatment (in any setting) include:
• Any surgical procedure that may be considered potentially
cosmetic.
• Any procedure, treatment, drug, or device that represents “new
or emerging technology.”
• Services that might be considered experimental/investigative.
If a member is seeking care out-of-network, that member’s
provider should be able to assist the member in determining
whether a proposed treatment falls into one of the categories
listed above. Members are encouraged to have their provider
initiate prior authorization.
Penalties for lack of prior authorization:
In-Network: It is the network provider’s responsibility to
obtain prior authorization for the services that are listed above.
Members are held harmless from payment if the network
provider does not obtain prior authorization.
Out-of-Network: It is the member’s responsibility to initiate
prior authorization for the services listed. The member will be
subject to payment in full if prior authorization is not obtained
for the inpatient/outpatient treatment services that are listed
above. Please note that in accordance with Medicare payment
rules, providers who do not participate with the Plan, must
accept as payment in full the amounts that could be collected
if the member was enrolled in Original Medicare, less any
applicable cost sharing.
This prior authorization list is subject to change.
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AmeriHealth PPO HSA-qualified High Deductible Health Plans Overview .....2
AmeriHealth PPO HSA-qualified High Deductible Health Plans
Professional Provider Copayment and Coinsurance Information ..................2
AmeriHealth PPO HSA-qualified High Deductible Health Plans
Benefit Information ....................................................................................4
In-Network Copayment/Deductible/Coinsurance Summary .........................12
Precertification Requirements ......................................................................13
Biotech/Specialty Injectables Information ....................................................15
Benefit Exclusions .......................................................................................16
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AmeriHealth PPO HSA-qualified High Deductible Health Plans (DE only)
AmeriHealth PPO HSA-qualified
High Deductible Health Plans (DE only)
AmeriHealth PPO HSA-qualified High
Deductible Health Plans Overview
Sample Personal Choice HSA-qualified High Deductible
Identification Card
Eight new AmeriHealth PPO HSA-qualified High
Deductible Health Plans provide employer groups the
opportunity to offer AmeriHealth PPO programs with benefit
designs that allow members to establish Health Savings
Accounts (HSAs). HSAs are member-owned personal savings
accounts and provide a tax-advantaged savings vehicle for
medical expenses. HSAs may only be used in conjunction with
HSA-qualified health plans.
Used when
integrated Rx
included in
HSA-qualified
HDHP
Identification Cards
On the member’s AmeriHealth PPO identification card
(ID), a line of text identifies the AmeriHealth PPO HSAqualified High Deductible Health Plan (HDHP) option in
which the member is enrolled. For example, an ID card that
reads HDHP–HD1-HC1 indicates that a member is enrolled
in a program that includes a $1,500 deductible for single
contracts and a $3,000 deductible for a family contract (HD1).
HC1 indicates that the member’s plan is an 80% network
coinsurance Plan—AmeriHealth pays 80% of Plan allowance
after deductible for most eligible services.
Please call Provider Services with questions regarding the new
AmeriHealth PPO HSA-qualified High Deductible Health
Plans.
In-Network Calendar Year
Deductible Options
AmeriHealth PPO HSA-qualified High
Deductible Health Plans: Professional
Provider Copayment and Coinsurance
Information
The new HSA-qualified High Deductible options offer
a choice of four standard deductible options that range
from $1,500 to $3,000. The chosen deductible option
can then be combined with a choice of two co-insurance
options of either 100% or 80%. A $20 copay is applicable to
preventive care visits and routine gynecological examinations
with no deductible. Routine mammograms and pediatric
immunizations are not subject to deductible or coinsurance.
HD1
HD2
HD3
HD4
$1,500 single
$3,000 family
$2,000 single
$4,000 family
$2,500 single
$5,000 family
$3,000 single
$6,000 family
One deductible option above should be combined with one coinsurance option below:
HC1
In Network Coinsurance Options
HC2
100%
80%
The chosen combination can include:
Integrated Prescription Drug
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Participating Caremark
Pharmacies:
$5 generic formulary/
$20 brand formulary/
$45 non-formulary
copayment after
deductible
Pharmacies:
$45 non-formulary
copayment after
deductible
Pharmacies:
$20 brand ormulary/
$45 non-formulary
copayment after
deductible
Pharmacies:
$45 non-formulary
copayment after
deductible
Non-Participating
Pharmacies: 50% after
deductible
Non-Participating
deductible
Non-Participating
deductible
Non-Participating
deductible
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01/06
Please note: Single deductible and out-of-pocket maximum
apply when an individual is enrolled without dependents.
Family deductible and out-of-pocket maximum apply when an
individual and one or more dependents are enrolled. The entire
family deductible must be met before benefits are paid.
Important differences between the existing standard
AmeriHealth PPO programs and the AmeriHealth PPO
HSA-qualified High Deductible Health Plans are:
• Office visits are subject to deductible and coinsurance;
however, network preventive office visits and routine
gynecological examinations are subject to a $20 office visit
copayment.
• Deductible and coinsurance apply to all Durable Medical
Equipment (DME) and prosthetics, including services that
are provided in a physician’s office.
When applicable, member copays may be collected at the
time of service (i.e., preventive office visits and routine
gynecological exams). For all other services in order to ensure
that members are billed correctly, claims should be adjudicated
by AmeriHealth before the member is billed.
Precertification Requirements
Precertification requirements for the AmeriHealth PPO
HSA-qualified High Deductible Health Plans are consistent with
those in the Flex Copay Series programs. Precertification is not
required for physical therapy, occupational therapy, speech
therapy, cardiac and pulmonary rehabilitation, and/or spinal
manipulations. These benefits have limits on the total number
of visits under the AmeriHealth PPO HSA-qualified High
Deductible Health Plans.
Physical and occupational therapy benefits are limited to 30
combined visits per calendar year. Speech therapy is limited to
20 visits per calendar year.
All injectables that are shown on the Biotech/Specialty
injectables list must be obtained through the Direct Ship
Program. Injectables are subject to applicable deductible and
coinsurance. Please note: Biotech/Specialty injectables that
are provided in the physician’s office and from a physician’s
supply are also subject to applicable Pharmacy Services prior
to the administration of any Biotech/Specialty injectable.
Precertification is required for the listed Biotech/Specialty
injectables and is facilitated via the Direct Ship process.
Standard office-based injectables, such as antibiotics and
steroids, are also subject to a member’s applicable deductible
and coinsurance.
01/06
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AmeriHealth PPO HSA-qualified High Deductible Health Plans Benefit Information
HD1-HC1
In-Network
Calendar Year
Deductible
Coinsurance
$1,500
Single
$3,000
Family
HD2-HC1
Out-ofNetwork
$5,000
Single
$10,000
Family
In-Network
$2,000
Single
$4,000
Family
Out-ofNetwork
$5,000
Single
$10,000
Family
HD3-HC1
In-Network
$2,500
Single
$5,000
Family
Out-ofNetwork
$5,000
Single
$10,000
Family
HD4-HC1
In-Network
$3,000
Single
$6,000
Family
Out-ofNetwork
$5,000
Single
$10,000
Family
100%
50%
100%
50%
100%
50%
100%
50%
Calendar Year Out-ofPocket Maximum
(includes deductible, copays
and coinsurance)
$5,250
Single
$10,500
Family
$10,000
Single
$20,000
Family
$5,250
Single
$10,500
Family
$10,000
Single
$20,000
Family
$5,250
Single
$10,500
Family
$10,000
Single
$20,000
Family
$5,250
Single
$10,500
Family
$10,000
Single
$20,000
Family
Lifetime Maximum
Unlimited
$500,000
Unlimited
$500,000
Unlimited
$500,000
Unlimited
$500,000
100%
after
deductible
100%
after
deductible
100%
after
deductible
50% after
deductible
Primary Care Office
Visit
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
OB-GYN Office Visit
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
Specialist Office Visit
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
Physical/Occupational
Therapy
30 visits per calendar year
combined in/out-of-network
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Outpatient Lab/
Pathology (fac & lab)
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Outpatient X-Ray/
Radiology/ Diagnostic
Routine Radiology/
Diagnostic MRI/MRA
CT/PET Scans
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Outpatient Mental
Health
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Outpatient Substance
Abuse
120 visits per lifetime
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Spinal Manipulations
Speech Therapy
Cardiac Rehab
36 sessions per calendar
year combined in/out-ofnetwork
Pulmonary Rehab
Orthoptic/Pleoptic
Therapy
8 sessions per lifetime
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100%
after
deductible
100%
after
deductible
100%
after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
01/06
HD1-HC1
HD2-HC1
HD3-HC1
100% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient
visit
calendar
year and
lifetime
maximums
100% after
deductible
50% after
deductible;
Serious
Mental Illness
out-of-network
outpatient
visits are
applied
toward
the Mental
Health Care
outpatient
visit calendar
year
maximum
50%, NO
deductible
$20
copay,
NO
deductible
$20
copay, NO
deductible
50%, NO
deductible
Mammography
100%, NO
deductible
Pediatric
Immunizations
HD4-HC1
100%
after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient
visit calendar
year and
lifetime
maximums
100% after
deductible
50% after
deductible;
Serious
Mental
Illness outof-network
outpatient
visits are
applied
toward
the Mental
Health Care
outpatient
visit
calendar
year
maximum
100%
after
deductible
50% after
deductible;
Serious
Mental
outpatient
visits are
applied
toward
the Mental
Health Care
outpatient
visit calendar
year
maximum
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%, NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
Injectable Medications
Standard injectables (e.g.
steroids)
Biotech/Specialty
Injectables
100% after
deductible
100% after
deductible
50% after
deductible
50% after
deductible
100% after
deductible
100% after
deductible
50% after
deductible
50% after
deductible
100% after
deductible
100% after
deductible
50% after
deductible
50% after
deductible
Maternity 1st Visit
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-of-network
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient
visit calendar
year and
lifetime
maximums
100% after
deductible
50% after
deductible;
Serious
Mental Illness
out-of-network
outpatient
visits are
applied
toward
the Mental
Health Care
outpatient visit
calendar year
maximum
Preventive Visits
(Pediatric/Adult)
$20
copay, NO
deductible
Routine Gynecological
Exam/Pap (1 per
calendar year regardless
of age, in/out-of-network
combined)
Outpatient Alcohol
and Drug Dependency
Outpatient Serious
Mental Illness
01/06
100% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-of-network
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient visit
calendar year
and lifetime
maximums
www.amerihealth.com
100%
after
deductible
100%
after
deductible
100%
after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
5 of 20
HD1-HC1
HD2-HC1
HD3-HC1
HD4-HC1
Home Health Care
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Chemo/Radiation/
Infusion
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Inpatient Hospital
Not waived if readmitted
within 90 days of discharge
100% after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
100% after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
100% after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
100%
after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
Outpatient Surgery
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Anesthesia
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Surgeon/Assistant
Surgeon
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
120 days per calendar year
in/out-of-network combined
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Hospice
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Inpatient Mental
Health
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Inpatient Substance
Abuse-Detox
7 days per admission
4 admissions per lifetime
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Inpatient Substance
Abuse-Residential
90 days per lifetime
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
Inpatient Alcohol and
Drug Dependency
Detox
6 of 20
100% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
Detox days
are applied
toward the
Substance
Abuse
Detox day
and lifetime
maximums
100% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
Detox days
are applied
toward the
Substance
Abuse
Detox day
and lifetime
maximums
100% after
deductible
www.amerihealth.com
50% after
deductible;
Alcohol
and Drug
Dependency
Detox days
are applied
toward the
Substance
Abuse
Detox day
and lifetime
maximums
100%
after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
Detox days
are applied
toward the
Substance
Abuse
Detox day
and lifetime
maximums
01/06
HD1-HC1
HD2-HC1
HD3-HC1
HD4-HC1
100%
after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-ofnetwork
Residential
days are
applied
toward the
Substance
Abuse
Residential
day
calendar
year and
lifetime
maximums
100%
after
deductible
50% after
deductible;
Serious
Mental
inpatient
days are
applied
toward
the Mental
Health Care
inpatient day
calendar
year
maximum
100% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-ofnetwork
Residential
days are
applied
toward the
Substance
Abuse
Residential
day
calendar
year and
lifetime
maximums
100% after
deductible
50% after
deductible;
Serious
Mental Illness
out-of-network
inpatient
days are
applied
toward
the Mental
Health Care
inpatient day
calendar
year
maximum
100% after
deductible
50% after
deductible;
Serious
Mental
inpatient
days are
applied
toward
the Mental
Health Care
inpatient day
calendar
year
maximum
Covered at
In-Network
level
100% after
deductible
Covered at
In-Network
level
100% after
deductible
Covered at
In-Network
level
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
Dialysis
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
Outpatient Private
Duty Nursing
360 hours per calendar
year in/out-of-network
combined
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
DME
100% after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
100% after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
100% after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
100%
after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
Prosthetics/Orthotics
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100% after
deductible
50% after
deductible
100%
after
deductible
50% after
deductible
100% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-of-network
Residential
days are
applied
toward the
Substance
Abuse
Residential
day calendar
year and
lifetime
maximums
100% after
deductible
50% after
deductible;
Serious
Mental Illness
out-of-network
inpatient days
are applied
toward
the Mental
Health Care
inpatient day
calendar year
maximum
Emergency Room
NOT waived if
admitted
100% after
deductible
Ambulance Transport
(elective)
Drug Dependency
Residential
Inpatient Serious
Mental Illness
100% after
deductible
In-Network
Calendar Year
Deductible
01/06
$1,500
Single
$3,000
Family
50% after
deductible;
Alcohol
and Drug
Dependency
out-of-network
Residential
days are
applied
toward the
Substance
Abuse
Residential
day calendar
year and
lifetime
maximums
Out-ofNetwork
$5,000
Single
$10,000
Family
In-Network
$2,000
Single
$4,000
Family
Out-ofNetwork
$5,000
Single
$10,000
Family
In-Network
$2,500
Single
$5,000
Family
www.amerihealth.com
Out-ofNetwork
$5,000
Single
$10,000
Family
100%
after
deductible
100%
after
deductible
100%
after
deductible
In-Network
$3,000
Single
$6,000
Family
Covered at
In-Network
level
50% after
deductible
50% after
deductible
Out-ofNetwork
$5,000
Single
$10,000
Family
7 of 20
HD1-HC1
Coinsurance
HD2-HC1
HD3-HC1
HD4-HC1
80%
50%
80%
50%
80%
50%
80%
50%
$5,100
Single
$10,200
Family
$10,000
Single
$20,000
Family
$5,100
Single
$10,200
Family
$10,000
Single
$20,000
Family
$5,100
Single
$10,200
Family
$10,000
Single
$20,000
Family
$5,100
Single
$10,200
Family
$10,000
Single
$20,000
Family
Lifetime Maximum
Unlimited
$500,000
Unlimited
$500,000
Unlimited
$500,000
Unlimited
$500,000
Primary Care Office
Visit
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
OB-GYN Office Visit
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Specialist Office Visit
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Physical/Occupational
Therapy
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Spinal Manipulations
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Speech Therapy
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Cardiac Rehab
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Pulmonary Rehab
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Orthoptic/Pleoptic
Therapy
8 sessions per lifetime
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Outpatient Lab/
Pathology (fac & lab)
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Outpatient X-Ray/
Radiology/ Diagnostic
Routine Radiology/
Diagnostic
MRI/MRA CT/PET Scans
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
Outpatient Mental
Health
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Outpatient Substance
Abuse
120 visits per lifetime
80% after
deductible
50% after
deductible
80% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Calendar Year Out-ofPocket Maximum
(includes deductible, copays
and coinsurance)
8 of 20
50% after
deductible
www.amerihealth.com
50% after
deductible
01/06
HD1-HC1
HD2-HC1
HD3-HC1
80% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient
visit
calendar
year and
lifetime
maximums
80% after
deductible
50% after
deductible;
Serious
Mental Illness
out-of-network
outpatient
visits are
applied
toward
the Mental
Health Care
outpatient
visit calendar
year
maximum
50%, NO
deductible
$20
copay,
NO
deductible
$20
copay, NO
deductible
50%, NO
deductible
Mammography
100%, NO
deductible
Pediatric
Immunizations
HD4-HC1
80% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient
visit calendar
year and
lifetime
maximums
80% after
deductible
50% after
deductible;
Serious
Mental
outpatient
visits are
applied
toward
the Mental
Health Care
outpatiient
visit
calendar
year
maximum
80% after
deductible
50% after
deductible
Serious
Mental
outpatient
visits are
applied
toward
the Mental
Health Care
outpatient
visit
calendar
year
maximum
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
$20
copay,
NO
deductible
50%, NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%, NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
100%,
NO
deductible
50%, NO
deductible
Standard injectables (e.g.
steroids)
Biotech/Specialty
Injectables
80% after
deductible
80% after
deductible
50% after
deductible
50% after
deductible
80% after
deductible
80% after
deductible
50% after
deductible
50% after
deductible
80% after
deductible
80% after
deductible
50% after
deductible
50% after
deductible
80% after
deductible
80% after
deductible
50% after
deductible
50% after
deductible
Maternity 1st Visit
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-of-network
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient
visit calendar
year and
lifetime
maximums
80% after
deductible
50% after
deductible;
Serious
Mental Illness
out-of-network
outpatient
visits are
applied
toward
the Mental
Health Care
outpatient visit
calendar year
maximum
Preventive Visits
(Pediatric/Adult)
$20
copay, NO
deductible
Routine Gynecological
Exam/Pap (1 per
calendar year regardless
of age, in/out-of-network
combined)
Outpatient Alcohol
and Drug Dependency
Outpatient Serious
Mental Illness
01/06
80% after
deductible
50% after
deductible;
Alcohol
and Drug
Dependency
out-of-network
outpatient
visits are
applied
toward the
Substance
Abuse
outpatient visit
calendar year
and lifetime
maximums
www.amerihealth.com
9 of 20
HD1-HC1
HD2-HC1
HD3-HC1
HD4-HC1
Home Health Care
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Chemo/Radiation/
Infusion
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Inpatient Hospital
Not waived if readmitted
within 90 days of discharge
80% after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
80% after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
80% after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
80% after
deductible
Unlimited
days
50% after
deductible
70 days per
cal/yr
Outpatient Surgery
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Anesthesia
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Hospice
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Inpatient Mental
Health
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Inpatient Substance
Abuse-Detox
7 days per admission
4 admissions per lifetime
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Inpatient Substance
Abuse-Residential
90 days per lifetime
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-of-network
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Detox days
year and
lifetime
maximums
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-of-network
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Detox days
year and
lifetime
maximums
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Detox days
year and
lifetime
maximums
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Detox days
year and
lifetime
maximums
Surgeon/Assistant
Surgeon
in/out-of-network combined
Drug Dependency
Detox
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HD1-HC1
HD2-HC1
HD3-HC1
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Residential
days year
and lifetime
maximums
80% after
deductible
50% after
deductible
Serious
Mental Illness
out-of-network
inpatient
days are
applied
toward
the Mental
Health Care
inpatient
days
calendar
year
maximums
Covered at
In-Network
level
80% after
deductible
80% after
deductible
50% after
deductible
Dialysis
80% after
deductible
Outpatient Private
Duty Nursing
360 hours per calendar
year in/out-of-network
combined
HD4-HC1
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-ofnetwork
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Residential
days year
and lifetime
maximums
80% after
deductible
50% after
deductible
Serious
Mental
inpatient
days are
applied
toward
the Mental
Health Care
inpatient
days
calendar
year
maximums
80% after
deductible
50% after
deductible
Serious
Mental
inpatient
days are
applied
toward
the Mental
Health Care
inpatient
days
calendar
year
maximums
Covered at
In-Network
level
80% after
deductible
Covered at
In-Network
level
80% after
deductible
Covered at
In-Network
level
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
DME
80% after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
80% after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
80% after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
80% after
deductible
50% after
deductible
$2,500
benefit max
per cal/yr
Prosthetics/Orthotics
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-of-network
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Residential
days year
and lifetime
maximums
80% after
deductible
50% after
deductible
Serious
Mental Illness
out-of-network
inpatient days
are applied
toward
the Mental
Health Care
inpatient days
calendar year
maximums
Emergency Room
NOT waived if admitted
80% after
deductible
Ambulance Transport
(elective)
Drug Dependency
Residential
Inpatient Serious
Mental Illness
80% after
deductible
50% after
deductible
Alcohol
and Drug
Dependency
out-of-network
outpatient
days are
applied
toward the
Substance
Abuse
outpatient
Residential
days year
and lifetime
maximums
Cost of Living Adjustment (COLA): The deductible and/or out-of-pocket maximum amounts may be adjusted annually for
inflation based on the Consumer Price Index or other index used by the Federal Government and rounded up to the nearest $50
increment.
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In-Network Copayment/Deductible/Coinsurance Summary
Office Visits
General Practice, Family Practice,
Internal Medicine, Pediatricians and OB/GYNs
Subject to Deductible and Coinsurance
Specialist Visits
Preventive Visits (Pediatric and Adult)
Pediatric Immunizations
Routine GYN/Pap
Subject to Copayment. No Deductible
100%, No Deductible
Subject to Copayment. No Deductible
Mammogram (Routine and Diagnostic)
100%, No Deductible
After Hours Visits
Home Visits
Telephone Consult
Spinal Manipulation
Not Covered
Therapy Services
Physical/Occupational, Speech, Cardiac Rehab,
Pulmonary Rehab, Orthoptic/Pleoptic
Outpatient Lab/Pathology
At time of physician office visit
Outpatient facility and lab
Routine Radiology/X-Ray/Diagnostic Services
Outpatient department of a hospital or freestanding
radiology site
Office Setting
Emergency Room
Complex Radiology Services
MRI/MRA, CT & PET Scans
Outpatient department of a hospital or freestanding
radiology site
Emergency Room
Allergy Injections
At time of physician office visit
Provided without physician office visit
Office-based or self-administered
Office-Based Surgery
Surgery in ER
Post Surgical Visits
Non-Routine GYN Visits
Routine Obstetrical Visits
First Obstetrical Visit
Subsequent Obstetrical Visits
DME
Emergency Room
Hospital Inpatient (includes acute care hospitals, mental
health and substance abuse treatment facilities)
Maternity Admissions
Outpatient Surgery
Outpatient Hospital
Birth Center
Ambulatory Surgi-center
ER Setting
Office Setting
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Precertification Requirements:
All services listed require precertification in-network and out-of-network (unless otherwise specified).
Inpatient Services
Acute Rehab
Inpatient Hospice
Maternity Admission (for notification only)
Outpatient Facility/Office Services (other than Inpatient)
Infusion Therapy (except cancer chemotherapy,
whole blood and blood plasma) in outpatient
facility and office
Hysterectomy
Cataract Surgery
Nasal Surgery for Submucous Resection, and
Septoplasty
Dental Services as a result of
Accidental Injury
Day Rehabilitation Programs
Comprehensive Outpatient Pain
Management Programs (including epidural injections)
Obesity Surgery
Sleep Studies
Radiological Services
MRI/MRA
CT/CTA Scan
PET Scan
Nuclear Cardiac Studies
Abdominoplasty
Blepharoplasty
Chemical Peels
Dermabrasion
Keloid Removal
Mastopexy
Otoplasty
Panniculectomy
Rhinoplasty
Scar Revision
Birthing Center (for notification only)
Prosthetics and Orthotics – Purchase items over $100, including repairs and
replacements
Durable Medical Equipment – Purchase items over $100, including repairs and
replacements, and ALL rentals (except oxygen, diabetic supplies, and unit dose medication for
nebulizer)
Biotech/Specialty Injectable Drugs
Psychiatric/Serious Mental Illness/Substance Abuse – Inpatient/Outpatient/Partial: Innetwork and out-of-network
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In addition to the precertification requirements listed above,
the member should contact AmeriHealth and provide prior
authorization for certain categories of treatment so that a
member will know prior to receiving treatment whether or
not it is a covered service. This applies to network providers
and members who elect to receive treatment provided
by AmeriHealth PPO or out-of-network providers. The
categories of treatment (in any setting) include:
cosmetic.
• Any procedure, treatment, drug, or device that represents
“new or emerging technology.”
Penalties for Lack of Precertification:
In-Network: It is the network provider’s responsibility to
obtain prior approval for the services that are listed above.
Members are held harmless from financial penalties if the
network provider does not obtain prior approval.
Out-of-Network: It is the member’s responsibility to initiate
precertification for the services listed. The member will be
subject to a 20% reduction in benefits if prior approval is not
obtained for the inpatient/outpatient treatment services that
are listed above.
This precertification list is subject to change annually.
A member’s provider should be able to assist the member in
determining whether a proposed treatment falls into one of
these three categories. Members are encouraged to have their
provider initiate prior authorization.
:
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Biotech/Specialty Injectables Information
For AmeriHealth PPO HSA-qualified High Deductible
Health Plan members, all injectables that are shown on the
Biotech/Specialty Injectables list require precertification.
Additionally, certain Biotech/Specialty Injectables require
medical necessity review. Please reference the latest Biotech/
Specialty Injectables list to determine which injectables require
medical necessity review. Also, look for updates to the Biotech/
Specialty Injectables list in future editions of Partners in Health
Update.
Procedures for Ordering and Billing Biotech/Specialty
Injectables for AmeriHealth HSA-qualified High
Deductible Health Plan members:
• All injectables shown on the Biotech/Specialty Injectables list
must be precertified through the Direct Ship Injectable Unit
of Pharmacy Services at (888) 671-5280, option 4.
• Contact the Direct Ship Injectable Unit of Pharmacy
Services at (888) 671-5280, option 4 to initiate a request for
precertification and to order Biotech/Specialty Injectables.
Note: You will be asked to complete the Direct Ship
Injectable Order Form to precertify and order Biotech/Specialty
injectables.
• The Direct Ship Injectable Unit of Pharmacy Services will
facilitate shipping of the Biotech/Specialty Injectables to your
office for administration, or to the member’s home for selfadministration.
• Biotech/Specialty Injectables provided in the physician’s office
from a physician’s supply are subject to the applicable
deductible and coinsurance described in the member’s
benefits. You must notify the Direct Ship Injectable Unit of
Pharmacy Services prior to the administration of any Biotech/
Specialty Injectables.
• To ensure that the member is billed correctly, claims for
Biotech/Specialty Injectables ordered through the Direct Ship
Injectable Unit should be adjudicated by AmeriHealth
before the member is billed. The injectable vendor will bill
members for their Biotech/Specialty Injectables.
• To ensure that the member is billed correctly, claims
should be adjudicated by AmeriHealth before the member
is billed for Biotech/Specialty Injectables provided from your
own supply.
Standard office-based injectables that are not shown on
the Biotech/Specialty Injectables list should not be ordered
through Pharmacy Services. You may continue to bill standard
injections, such as antibiotics and steroids, through the
patient’s medical plan.
If you have any questions concerning ordering injectables,
please call the Direct Ship Unit of Pharmacy Services at
(888) 671-5280, option 4. You may also access the Direct Ship
on our website http://www.amerihealth.com/providers/resources/
pharmacy/index.html.
• Failure to precertify any of the Biotech/Specialty Injectables
on the following list will result in a claims denial. Claims
denied for failure to precertify are not billable to the
member.
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Benefit Exclusions
What is not covered:
Except as specifically provided in this booklet/certificate, no
benefits will be provided for services, supplies or charges:
• Which are not Medically Appropriate/Medically Necessary
as determined by the Carrier for the diagnosis or treatment
of illness or injury;
• Which are Experimental/Investigative in nature, except as
approved by the Carrier, Routine Costs Associated With
Clinical trials that meet the definition of Qualifying Clinical
Trial under this booklet/certificate;
• Which were incurred prior to the Covered Person’s effective
date of coverage;
• Which were or are incurred after the date of termination
of the Covered Person’s coverage except as provided in the
General Information section;
• For any loss sustained or expenses incurred during military
service while on active duty as a member of the armed forces
of any nation; or as a result of enemy action or act of war,
whether declared or undeclared;
• For which a Covered Person would have no legal obligation
to pay;
• That are received from a dental or medical department
maintained by or on behalf of an employer, a mutual benefit
association, labor union, trust, or similar person or group;
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• For payment made under Medicare when Medicare is
primary or would have been made if the Covered Person
had enrolled for Medicare and claimed Medicare benefits;
however, this exclusion shall not apply when the Group is
obligated by law to offer the Covered Person all the benefits
of this Plan and the Covered Person so elects this Plan as
primary;
• For any occupational illness or bodily injury that occurs in
the course of employment if benefits or compensation are
available, in whole or in part, under the provisions of the
Worker’s Compensation Law or any similar Occupational
Disease Law or Act. This exclusion applies whether or not
the Covered Person claims the benefits or compensation;
• To the extent a Covered Person is legally entitled to receive
when provided by the Veteran’s Administration or by the
Department of Defense in a government facility reasonably
accessible by the Covered Person;
• For injuries that result from the maintenance or use of a
motor vehicle if such treatment or service is paid under
a plan or policy of motor vehicle insurance, including a
certified self insured plan;
• Which are not billed and performed by a Provider as
defined under this coverage as a “Professional Provider”,
“Facility Provider” or “Ancillary Provider” except as otherwise
indicated under the subsections entitled: (a) Therapy
Services” (that identifies covered therapy services as provided
by licensed therapists) and (b) “Ambulance Services” in the
Description of Benefits;
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• Which are rendered by a member of the Covered Person’s
Immediate Family;
• For marriage counseling;
• For Custodial Care, domiciliary care or rest cures;
• Which are performed by a Professional Provider enrolled
in an education or training program when such services
are related to the education or training program and are
provided through a Hospital or university;
• For ambulance services except as specifically provided under
this Plan;
• For services and operations for cosmetic purposes that are
done to improve the appearance of any portion of the body,
and from which no improvement in physiologic function
can be expected. However, benefits are payable to correct
a condition that results from an accident. Benefits are also
payable to correct functional impairment which results from
a covered disease, injury or congenital birth defect. This
exclusion does not apply to mastectomy related charges as
provided for and defined in the “Surgical Services” section in
the Description of Benefits;
• For telephone consultations, charges for failure to keep a
scheduled visit, and/or charges for completion of a claim
form;
• For Alternative Therapies/Complementary Medicine,
including but not limited to, acupuncture, music therapy,
dance therapy, equestrian/hippotherapy, homeopathy,
primal therapy, rolfing, psychodrama, vitamin and/or
other dietary supplements and therapy, naturopathy,
hypnotherapy, bioenergetic therapy Qi Gong, Ayurvedic
therapy, aromatherapy, massage therapy, therapeutic touch,
recreational, wilderness, educational and sleep therapies;
• For equipment costs that are related to services that are
performed on high cost technological equipment as defined
by the Carrier, such as, but not limited to, computer
tomography (CT) scanners, magnetic resonance imagers
(MRI) and linear accelerators, unless the acquisition of
such equipment by a Professional Provider was approved
through the Certificate of Need (CON) process and/or by
the Carrier;
• For dental services relating to the care, filling, removal or
replacement of teeth (including dental implants to replace
teeth or to treat congenital anodontia, ectodermal dysplasia
or dentinogenesis imperfecta), and the treatment of injuries
to or diseases of the teeth, gums or structures directly
supporting or attached to the teeth, except as otherwise
specifically stated in this booklet/certificate. Services
not covered include, but are not limited to, apicoectomy
(dental root resection), prophylaxis of any kind, root canal
treatments, soft tissue impactions, alveolectomy, bone
grafts or other procedures provided to augment an atrophic
mandible or maxilla in preparation of the mouth for dentures
or dental implants, and/or treatment of periodontal disease
unless otherwise indicated;
• For dental implants for any reason;
• For dentures, unless for the initial treatment of an Accidental
Injury/trauma;
• For orthodontic treatment, except for appliances used for
palatal expansion to treat congenital cleft palate;
• For injury as a results of chewing or biting (neither is
considered an Accidental Injury);
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• For palliative or cosmetic foot care including treatment
of bunions (except for capsular or bone surgery), toenails
(except surgery for ingrown nails), the treatment of
subluxations of the foot, care of corns, calluses, fallen arches,
pes planus (flat feet), weak feet, chronic foot strain, and other
routine podiatry care, unless associated with the Medically
Appropriate/Medically Necessary treatment of peripheral
vascular disease and/or peripheral neuropathic disease,
including but not limited to diabetes;
• For any treatment that leads to or in connection with
transsexual Surgery except for sickness or injury resulting
from such Surgery;
• For treatment of a sexual dysfunction not related to organic
disease, except for sexual dysfunction resulting from an
injury;
• For treatment of obesity, except for surgical treatment of
morbid obesity when: (a) the Carrier determines the surgery
is Medically Appropriate/Medically Necessary, and (b) the
surgery is not a repeat, reversal or revision of any previous
obesity surgery. The exclusion of coverage for a repeat,
reversal, or revision of a previous obesity surgery does not
apply when the procedure is required to treat complications,
which, if left untreated, would result in an endangerment of
the health of the Covered Person;
• For eyeglasses, lenses, or contact lenses and the vision
examination for prescribing or fitting eyeglasses or contact
lenses unless otherwise indicated;
• For correction of myopia or hyperopia by means of corneal
microsurgery, such as keratomileusis, keratophakia, and radial
keratotomy and all related services;
• For weight reduction and premarital blood tests;
• For health foods, dietary supplements, or pharmacological
therapy for weight reduction or diet agents;
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• For diagnostic screening examinations, except as provided in
the “Primary and Preventive Care” section of the Description
of Benefits;
• For routine physical examinations for non-preventive
purposes, such as pre-marital examinations, physicals for
college, camp or travel, and examinations for insurance,
licensing and employment;
• For travel, whether or not it has been recommended by a
Professional Provider or if it is required to receive treatment
at an out of area Provider;
• For immunizations that are required for employment
purposes, and/or for travel;
• For care in a nursing home, home for the aged, convalescent
home, school, institution for retarded children, Custodial
Care in a Skilled Nursing Facility;
• For counseling or consultation with a Covered Person’s
relatives, or Hospital charges for a Covered Person’s relatives
or guests, except as may be specifically provided or allowed in
the “Treatment for Alcohol or Drug Abuse and Dependency”
or “Transplant Services” sections of the Description of Benefits;
• For home blood pressure machines, except for Covered
Persons: (a) with pregnancy-induced hypertension, (b) with
hypertension complicated by pregnancy, or (c) with end-stage
renal disease receiving home dialysis;
• As described in the “Durable Medical Equipment” and
“Prosthetic Devices” sections in the Description of Benefits: for
personal hygiene, comfort and convenience items; equipment
and devices of a primarily nonmedical nature; equipment
inappropriate for home use; equipment containing features
of a medical nature that are not required by the Covered
Person’s condition; non-reusable supplies; equipment which
cannot reasonably be expected to serve a therapeutic purpose;
duplicate equipment, whether or not rented or purchased as a
convenience; devices and equipment used for environmental
control; and/or customized wheelchairs;
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• For medical supplies such as, but not limited to,
thermometers, ovulation kits, and early pregnancy or home
pregnancy testing kits;
• For contraceptive devices, except as may be provided by a
family planning rider attached to this booklet/certificate;
• For Cognitive Rehabilitation Therapy, which is a therapeutic
approach designed to improve cognitive functioning after
central nervous system injury or trauma. It includes therapy
methods that retrain or alleviate problems caused by deficits
in attention, visual processing, language, memory, reasoning
and problem solving. It utilizes tasks that are designed to
reinforce or reestablish previously learned patterns of behavior
or to establish new compensatory mechanisms for the
impaired neurologic system);
• For over-the-counter drugs and any other medications that
may be dispensed without a doctor’s prescription, except for
medications administered during an Inpatient Admission;
• For charges incurred by a Covered person while incarcerated
in any adult or juvenile penal or correctional facility or
institution;
• For amino acid supplements, non-elementals formulas,
appetite suppressants or nutritional supplements, including
basic milk, soy, or casein hydrolyzed formulas (e.g.,
Nutramigen, Alimentun, Pregestimil) for the treatment of
lactose intolerance, milk protein intolerance, milk allergy or
protein allergy;
• For Hearing Aids, including cochlear electromagnetic
hearing devices, and/or hearing examinations or tests for
the prescription or fitting of Hearing Aids, except as may
be provided by a Hearing Aids benefit rider attached to this
booklet/certificate. Services and supplies related to these
items are not covered;
• For Inpatient Private Duty Nursing services;
• For assisted fertilization techniques such as, but not limited
to, in-vitro fertilization, gamete intra-fallopian transfer
(GIFT), and/or zygote intra-fallopian transfer (ZIFT),
except as may be provided by an assisted fertilization benefits
rider attached to this booklet/certificate;
• For prescription drugs, except as may be provided by a
prescription drug rider attached to this booklet/certificate;
• For any care that extends beyond traditional medical
management for autistic disease of childhood, Pervasive
Development Disorders, Attention Deficit Disorder, learning
disabilities, behavioral problems, or mental retardation;
and/or treatment and/or care to effect environmental or social
change;
• For cranial prostheses, including wigs intended to replace hair,
except as may be provided by a wig benefit rider attached to
this booklet/certificate;
• For maintenance of chronic conditions;
• For charges incurred for expenses in excess of Benefit
Maximums as specified in the Schedule of Benefits;
• For any therapy service provided for: the ongoing Outpatient
treatment of chronic medical conditions that are not subject
to significant functional improvement; additional therapy
beyond this Plan’s limits, if any, shown on the Schedule of
Benefits; work hardening; evaluations not associated with
therapy; and/or therapy for back pain in pregnancy without
specific medical conditions;
• For supportive devices for the foot (orthotics), such as, but
not limited to, foot inserts, arch supports, heel pads and heel
cups, and orthopedic/corrective shoes. This exclusion does not
apply to orthotics and podiatric appliances required for the
prevention of complications associated with diabetes;
• For treatment of temporomandibular joint syndrome (TMJ),
also known as craniomandibular disorders (CMD), with
intraoral devices or with any non-surgical method to alter
vertical dimension;
• For any surgery performed to reverse a sterilization procedure;
• For any other service or treatment except as provided under
this Plan.
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AmeriHealth New Jersey 51+ HMO Plus (without Referrals) Information ..............2
AmeriHealth HMO Plus Preapproval/Precertification Requirements .....................3
Product Overview
ID Cards
AmeriHealth HMO, Inc. (AmeriHealth) is pleased to
introduce a new HMO program, AmeriHealth New Jersey
51+ HMO Plus. This booklet contains information regarding
the AmeriHealth New Jersey 51+ HMO Plus product, which
is available to large employer groups in New Jersey. The
AmeriHealth New Jersey HMO Plus program is effective
December 1, 2005.
An AmeriHealth New Jersey HMO Plus program member
will carry an identification card that clearly indicates the
member is enrolled in an HMO Plus product. On the
member’s identification card, a line of text identifies the
product and the office copayment. These codes correlate to the
benefit options shown in the enclosed Benefit Guide.
The AmeriHealth New Jersey HMO Plus product requires
members to choose a Primary Care Physician (PCP) in the
AmeriHealth network; however, members can access
in-network care without a referral. The Plus means NO
referral is required. The PCP copay will apply when the
member visits any network PCP. Payments to PCPs for
these members will be listed as fee for service.
For your reference and convenience, this booklet contains
copayment, preapproval, and additional information that
is applicable to the AmeriHealth New Jersey HMO Plus
product.
OB/GYN Note: AmeriHealth New Jersey HMO Plus
members will pay a PCP copayment, not a specialist
copayment, for OB/GYN visits. This will not be reflected on
the member’s ID card.
Please call Provider Services with questions regarding this new
product.
Sample AmeriHealth New Jersey HMO Plus ID Card
Referral Requirements
AmeriHealth New Jersey HMO Plus—Members can access
care in-network without a referral. A PCP or specialist
copay will apply when a member visits any network PCP or
specialist.
Radiology Network
Members will receive the highest level of benefits when
services are received from radiologists who participate in the
sub-network.
Provider Note
Please insert this product booklet into the “Products” section
of your Provider Manual.
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AmeriHealth New Jersey 51+ HMO Plus (without Referrals) Health Plan (NJ only)
AmeriHealth New Jersey 51+ HMO Plus
(without Referrals) Health Plan (NJ only)
AmeriHealth New Jersey 51+ HMO Plus (without Referrals)
BENEFITS
Deductible
OOP Maximum*
Lifetime Maximum
Inpatient Hospital Days (Medical)
PCP Visit
OB/GYN Visit
Maternity 1st Visit
Specialist Visit
Immunizations (subject to office visit copay)
Mammography
ER care (copay not waived if admitted)
Hospital Care **
Outpatient Surgery (facility)**
Outpatient Therapy
PT/OT (30 visits/cal yr combined)
Speech Therapy (20 visits/cal yr)
Cardiac Rehab Therapy (36 sessions/cal yr)
Pulmonary Rehab Therapy (36 sessions/
cal yr)
Orthoptic/Pleoptic Therapy (8 sessions/
lifetime combined)
Therapeutic Manipulations (20 visits/cal yr)
Outpatient X-Ray/Radiology/Diagnostic
Services
- Routine Radiology Diagnostic
- MRI/MRA, CT Scan, PET Scans** (No
copay applicable when service performed
in ER or office setting)
Chemotherapy/Radiation/Infusion Therapy
Lab
SNF - 120 days/cal yr**
Home Health**
Hospice**
Ambulance
Outpatient PDN – 360 hrs/cal yr**
DME**
Prosthetic**
Mental Health
- Inpatient** (30 days/cal yr)
- Outpatient (20 visits/cal yr)
Serious Mental Illness and Alcohol Abuse
- Inpatient**
HMO Plus
$15/$30
$0/Day
HMO Plus
$15/$30
$200/Day
HMO Plus
$20/$40
$0/Day
HMO Plus
$20/$40
$300/Day
HMO Plus
$30/$50
$0/Day
HMO Plus
$30/$50
$400/Day
NONE
$5,000/$10,000
Unlimited
Unlimited
$15
$15
$15
$30
100%
100%
$100
100%
NONE
$5,000/$10,000
Unlimited
Unlimited
$15
$15
$15
$30
100%
100%
$100
$200/day up to 5 days
NONE
$5,000/$10,000
Unlimited
Unlimited
$20
$20
$20
$40
100%
100%
$100
100%
NONE
$5,000/$10,000
Unlimited
Unlimited
$20
$20
$20
$40
100%
100%
$100
NONE
$5,000/$10,000
Unlimited
Unlimited
$30
$30
$30
$50
100%
100%
$100
100%
100%
$100
100%
$150
100%
NONE
$5,000/$10,000
Unlimited
Unlimited
$30
$30
$30
$50
100%
100%
$100
$400/day up to
5 days
$200
$30
$30
$40
$40
$50
$50
$30
$30
$30
$30
$40
$40
$40
$40
$50
$50
$50
$50
$30
$30
$40
$40
$50
$50
$30
$30
$40
$40
$50
$50
$30
$30
$40
$40
$50
$50
$30
$60
$30
$60
$40
$80
$40
$80
$50
$100
$50
$100
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
90%
50%
50%
100%
100%
100%
100%
90%
50%
50%
100%
100%
100%
100%
100%
85%
50%
50%
100%
100%
100%
100%
85%
50%
50%
100%
100%
100%
100%
100%
80%
50%
50%
100%
$200/day up to
5 days
100%
100%
100%
80%
50%
50%
100%
100%
100%
$30
$30
$40
$40
$50
$400/day up to
5 days
$50
100%
100%
100%
$400/day up to
5 days
$50
- Outpatient
Substance Abuse
- Inpatient** (30 days/cal yr)
Unlimited lifetime maximum
$30
$30
$40
$40
$50
100%
100%
100%
$400/day up to
5 days
- Outpatient (30 visits/cal yr)
120 visits/lifetime
$30
$30
$40
$40
$50
$50
* Annual Out-of-Pocket (OOP) Maximum per person/per family; copayments and coinsurance apply to OOP Max.
** Precertification Required.
2 of 4
www.amerihealth.com
01/06
AmeriHealth HMO Plus Preapproval/Precertification Requirements
Inpatient Services
Acute Rehab
Skilled Nursing Facility (SNF)
Inpatient Hospice
Maternity Admission (for notification only)
Outpatient Facility/Office Services (other than Inpatient)
Infusion Therapy (except cancer chemotherapy, whole blood
and blood plasma) in outpatient facility and office
Hysterectomy
Cataract Surgery
Nasal Surgery for Submucous Resection and Septoplasty
PET Scans, MRI, MRA, CT, and Nuclear Cardiac Studies
Comprehensive Outpatient Pain Management
Programs (including epidural injections)
Obesity Surgery
Sleep Studies
Otoplasty
Panniculectomy
Rhinoplasty
Scar Revision
Abdominoplasty
Blepharoplasty
Chemical Peels
Dermabrasion
Keloid Removal
Mastopexy
Birthing Center (for notification only)
Prosthetics and Orthotics – Purchase items over $100, including repairs and replacements
Durable Medical Equipment (DME) – Purchase items over $100, including repairs and
replacements, and ALL rentals (except oxygen, diabetic supplies, and/or unit dose medication for nebulizer)
Mental Health/Serious Mental Illness/Substance Abuse/Alcohol Abuse
Outpatient Mental Health Treatment/Outpatient Substance Abuse Treatment (not alcohol abuse)
Inpatient Mental Health Treatment/Inpatient Substance Abuse Treatment
Inpatient Serious Mental Illness Treatment/Inpatient Alcohol Abuse Treatment
01/06
www.amerihealth.com
3 of 4
Preapproval
Penalties
Preapproval is not a determination of eligibility or a guarantee
of payment. Coverage and payment are contingent upon—
among other things—the member being eligible (i.e., actively
enrolled in the health benefits plan when the preapproval
is issued and when approved services occur). Coverage and
payment are also subject to limitations, exclusions, and/or
other specific terms of the health benefits plan that apply to
the coverage request. The preapproval list is subject to change.
HMO Plus In-Network: It is the network provider’s
responsibility to obtain preapproval for services listed.
Members are held harmless from financial penalties if the
network provider does not obtain approval.
The provider should contact AmeriHealth and provide
prenotification (prior authorization) for certain categories
of treatment so that the member will know prior to receiving
treatment whether it is a covered service. This also applies
to network providers. Those categories of treatment (in any
setting) include:
cosmetic.
• Any procedure, treatment, drug, and/or device that represents
“new or emerging technology.
You should be able to assist the member in determining
whether a proposed treatment falls into one of these three
categories.
ALL
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LABEL
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COUNCIL
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www.amerihealth.com
01/06
Outpatient Management of Uncomplicated Deep Vein Thrombosis
(DVT) with Low Molecular Weight Heparin (LMWH)
All members with medical benefits are eligible to receive LMWH for home treatment of DVT. A pharmacy benefit is
not required. For a listing of participating providers of LMWH at home, please refer to the provider names and contact
numbers below or visit www.amerihealth.com.
Step 1
Is the patient
medically
eligible for
outpatient
treatment with
LMWH?
CONTRAINDICATIONS
• Active major bleeding.
• Hypersensitivity to enoxaparin, heparin, pork products.
• Hypersensitivity to benzyl alcohol (multi-dose formulation).
• History of thrombocytopenia associated with enoxaparin.
• Patient or caregiver unable or unwilling to administer subcutaneous medication at home OR to interact
with home health caregivers.
• History of heparin-induced thrombocytopenia.
PRECAUTIONS
• Active or history of recent GI ulceration or hemorrhage.
• Bacterial endocarditis.
• Bleeding diathesis.
• Concomitant neuraxial anesthesia or spinal puncture and low molecular weight heparins use increases the
risk of epidural or spinal hematoma.
• Concomitant platelet inhibitors (discontinue unless really needed including ASA, NSAIDs, dipyridamole, or
sulfinpyrazone).
• Congenital or acquired bleeding disorders.
• Diabetic retinopathy.
• Hemorrhagic stroke.
• Not adequately studied for thromboprophylaxis in patients with prosthetic heart valves
• Recent brain, spinal, or ophthalmological surgery.
• Renal impairment (dosage adjustment for severe impairment, create clearance <30 ml/min)
• Uncontrolled hypertension.
• Other high risk – Confirmed/suspicion of pulmonary embolus, failure of outpatient treatment, high risk for
falls/trauma, morbid obesity, more than 2 previous episodes of DVT, recurrent DVT within last 3 months,
immobilization.
• Age younger than 18 years.
Step 2
Begin Protocol
• Obtain Baseline CBC/platelet count , serum creatinine PTT, PT/INR.
• Instruct patient/family in subcutaneous injection if willing.
• Call infusion company to set up home delivery of LMWH. Nursing visits may be requested to check
compliance with self injections, instruct member or family or administer injections if member/family unable.
• Instruct patient/family regarding their disease, treatment plan, risks, signs and symptoms of bleeding, the
importance of compliance, and emergency numbers/contacts.
• Contact AmeriHealth case management at (800) 313-8628 if assistance is required.
Step 3
Begin
Treatment
• Start subcutaneous injection of LMWH; standard dose is 1mg/kg every 12hours.
• Start warfarin (5 mg) on day 1; subsequent daily dosing to be adjusted based on INR.
• Arrange for PT/INR on day three and adjust the subsequent daily dose according to INR.
• Check a platelet count between days 3 to 5 of LMWH therapy.
• Discontinue LMWH after at least 5 days of combined therapy when the INR is within therapeutic range
(2.0-3.0).
• Continue anticoagulation therapy with warfarin for at least 3 months at INR within therapeutic range
(2.0-3.0).
Special
Considerations
If availability of outpatient services is unable to be confirmed, inpatient observation status may be considered
until these can be obtained.
References
1. Sixth ACCP Consensus Conference on Antithrombotic Therapy, Chest 2001:119 (1 Supppl);1S-370S.
Hyers TM, Agnelli G, Hull RD et al. “Antithromobtic Therapy for Venous Thromobembolic Disease,” Chest
2001:119:176S-193S.
2. Thomson Micromedex, Greenwood Village, Colorado.
STAT Low Molecular Weight Heparin (LMWH) Program
Provider Name
Contact Number
Penn Home Infusion
(610) 992-3998
Neighborcare
(610) 205-1313
Burman’s Home Health Care
(610) 364-3160 x15
Option Care Horsham
(610) 941-0129
Professional Home Care
(610) 323-8750
Home Healthcare Resources
(215) 245-1888
Pediatric Services of America
(800) 454-3798
SNI
(267) 532-1663
Praxair
(215) 238-0121
Option Care Chester County
(610) 334-0450
Ambulatory Pharmaceutical
Services DBA US Bioservices
(800) 400-9549
Home Solutions
(800) 447-4879 x 211
AmeriHealth HMO, Inc., QCC Insurance Company, d/b/a/ AmeriHealth Insurance Company
Partners in Health
2005 Cumulative Index: January - December
Partners in Health Monthly Update & Quarterly Clinical Update
Current and archived issues of Partners in Health monthly Update, quarterly Clinical Update, the Provider Manual, and quarterly
Coding Guidelines and Policy Update (CGPU), including the CGPU Compendium, which is a collection of relevant policy
summaries that have been published within the respective year, are available in PDF format via NaviNetSM and
in the Provider section of the website at www.amerihealth.com/providers.
-AA View Inside From the Medical Directors
Winter 2004 Clinical Update
Spring Clinical Update
Summer Clinical Update
AmeriHealth New Jersey Transitioned to AllElectronic Encounter and Referral Submission
September Update
October Update
November Update
December Update
AdvancePCS Changes Name to “Caremark®”
April Update
AmeriHealth POS Plus Quick Reference Guide
(Enclosure)
March Update
Age Edits on Paxil® (paroxetine) and Effexor®
(venlafaxine) for all Prescription Drug Programs
February Update
-B-
AIM Precertification Requirement for Radiology
Services, Effective January 1, 2005
January Update
AmeriHealth Contracts With
Council for Affordable Quality Healthcare
For Universal Credentialing DataSource
August Update
AmeriHealth Delaware Benefit Clarifications for
HMO, PPO, POS: Maintenance Definition, Waiver
Policy, and Benefit Enhancement
AmeriHealth Implementing Radiology Quality
Initiative for Delaware Members Effective
August 1, 2005 (Delaware only)
July Update
AmeriHealth New Jersey Transitioning to AllElectronic Encounter and Referral Submission
April Update
May Update
June Update
July Update
August Update
Benefit Clarifications for AmeriHealth
(Delaware only)
March Update
(Important AmeriHealth) Billing Information for
AmeriHealth PPO, Traditional Medical/Preferred
Provider Network, and Comprehensive Major
Medical (CMM) Products
January Update
(Sidebar: Important) Billing Requirements
December Update
Billing Requirement: Use Complete Member
ID Number
January Update
February Update
March Update
May Update
June Update
July Update
August Update
September Update
October Update
November Update
December Update
Billing Requirements for Outpatient Radiology
and Lab Services at Participating Hospitals
February Update
ALL
R
TRADES
IED PRINTING
UNION
LABEL
COUNCIL
SCRANTON
13
AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey •
QCC Insurance Company d/b/a AmeriHealth Insurance Company
Page 1 of 8
Biotech/Specialty Injectables Information for
Flex Programs (Enclosure)
June Update
November Update
Claims with More Than One Unit of Time for
Speech-Pathology Codes Will Reject
April Update
(Women’s Health Programs): Cervical Cancer
Prevention
-CCeliac Disease: Increasing Awareness and
Addressing the Diagnostic Challenge
(Women’s Health): Cervical Cancer Prevention
Change to the Services Paid Above Capitation List
(Delaware only)
August Update
Cholesterol Management: Adult Treatment
Panel III Guidelines Update
(Men’s Health): Cholesterol Management, Obesity
and Proper Nutrition, Immunization
Recommendations, and Colorectal and Prostate
Cancer Screenings
(Providing PHI to Employer Groups Acting As)
Claims Fiduciaries
April Update
Claims Overpayment and Refunds Address
June Update
(Avoid) Claims Rejections
January Update
February Update
March Update
(More Information Regarding)
Claims Submissions
August Update
Class Action Settlement Update:
(Announcements, Settlements Payment Policy and
Processing Update, Settlement Recap, Modifier 50,
Implementation Recap)
October Update
Class Action Settlement Update:
(Clear Claim Connection, Settlements payment
Policy, and Processing Update, Announcements,
Modifier 51 Exempt, Modifier 66 form,
Implementation Recap, Settlement recap,
Radiologic Guidance of a Procedure, Surgical
Documentation Form)
December Update
(Women’s Health Programs): Clinical Breast
Examinations (CBEs) Are Essential to Breast
Cancer Prevention
Clinical Criteria for Utilization Management
Decisions
December Update
(Free, Online) CME: Long-term Beta Blocker
Adherence Post-Myocardial Infarction
February Update
(Use the Standard) CMS 1500 Form when
submitting paper claims
April Update
Colorectal Cancer “No Excuses” brochure
(Enclosure)
April Update
Colorectal Cancer Prevention Pocket Card
(Enclosure)
April Update
(Encourage Members to Receive) Colorectal
Cancer Screening
February Update
(Member’s Health Update: Important Information
Regarding) Colorectal Cancer Screening in DE
(Enclosure)
April Update
(Member’s Health Update: Important Information
Regarding) Colorectal Cancer Screening in NJ
(Enclosure)
April Update
Colorectal Cancer Screening Initiative
Colorectal Cancer Screening Materials Order Form
April Update
Common Errors in Vaccine Handling and Storage
Page 2 of 8
(Launch of the New) ConnectionsSM
AccordantCareTM Program Adds Fifteen
New Chronic Care Conditions to the
ConnectionsSM Programs
June Update
Connections Health Management Programs Adds
New Line of Business
December Update
(New) ConnectionsSM AccordantCareTM Program
Expands Disease Management for Members
with Chronic Diseases
(2005) ConnectionsSM Annual Update (Enclosure)
November Update
ConnectionsSM Health Management Programs:
Congestive Heart Failure Member Outreach
ConnectionsSM Health Management Programs
Decision Support Campaigns
Gap Campaigns
ConnectionsSM Health Management Programs Supporting Our Members, Your Patients
January Update
February Update
March Update
April Update
July Update
August Update
September Update
October Update
(New) Coordination of Benefits (COB) Form
Available via NaviNetSM
June Update
Coordination of Benefits Questionnaire
(Enclosure)
June Update
(Reminder to Use the Most Current Version of the
AmeriHealth) Credentialing Application
February Update
Credentialing Compliance Hotline and Web Page
February Update
April Update
June Update
August Update
October Update
December Update
-D(Policy Update for) Decavac™
Deep Vein Thrombosis and Pulmonary Embolism:
Early Recognition and Treatment
Delaware Newborn Hearing Screening Mandate
December Update
Dermatopathology Services
August Update
(New) Diagnostic Imaging Services Improve
Radiology Testing for AmeriHealth
(Delaware Only)
April Update
May Update
June Update
Diagnosing and Treating Depression
Fall Clinical Update
Drug Program Information Available On
Our Website
June Update
(Passive Enrollment of) Dual Eligibles into
AmeriHealth 65 (PA Only)
December Update
-E(AmeriHealth New Jersey to Transition to)
Electronic Referral Submission
March Update
(AmeriHealth New Jersey Transitioned to) AllElectronic Encounter and Referral Submission
September Update
October Update
December Update
(Updated) Electronic and Paper Referral Forms
Buckslip (Enclosure)
March Update
Emergency Room Utilization Review for
Emergency Room Overuse
November Update
Encounter/Referral Buckslip (Enclosure)
March Update
Page 3 of 8
Enhancements to Policy, Payment, Disclosure,
and Appeals Processes for Class Action
Settlement Providers
April Update
ePocrates Rx® for Palm® OS and Pocket PC
Personal Digital Assistants
Extracorporeal Shock Wave Therapy (ESWT) for
Musculoskeletal Conditions and Plantar Fasciitis
February Update
-FFDA Issues Public Health Advisory on Depression
in Children and Adolescents
(How) Fee for Procedures and Professional
Services are Developed for New and Revised
Codes
November Update
Field 19 Requirement: Paper or Electronic
Referrals Must be on File for Claims to Process
April Update
(Delaware AmeriHealth) Flex Programs
Biotech/Specialty Injectables Update
June Update
November Update
(Continued Success in Addressing) Fraud
and Abuse
April Update
-G(ICD-9-CM Diagnosis Codes Change for Routine)
Gynecological Exam
December Update
-H(Expanded and Revised) Hand Therapy Diagnosis
Reminder (Delaware only)
August Update
HealthGrades® Hospital Quality Reports Offered
at Discount (Sidebar)
July Update
HealthGrades®
Patient Safety Data Added to
Enhanced Online Provider Search
July Update
(AmeriHealth) Healthy LifestylesSM Programs
Provides Incentive for Members
heartBBEAT for life® Initiative
(Removal of Referrals for) Hemodialysis
December Update
(End Date of) HIPAA Transactions and Code Sets
(TCS) Contingency Plan
April Update
May Update
(New) HMO Program in New Jersey: Individual
Preferred Plan
May Update
Hospital Listing and Associated 10-Digit Provider
Identification Numbers (Enclosure)
April Update
-IICD-9-CM Diagnosis Codes Change for Routine
Gynecological Exams
December Update
(Printable Temporary Member) Identification
Information is Available Effective December 17,
2005
December Update
ID Cards with New 13-Position Member
Identification Number Now Being Issued
April Update
May Update
June Update
July Update
August Update
(Revised Adolescent) Immunization
Recommendations
Immunization Schedules
Influenza and Pneumococcal Awareness and
Intervention
Individual Preferred Health Plan Product booklet
(Enclosure)
May Update
Initial Maternity Patient Questionnaire Update
June Update
Page 4 of 8
(Enhanced Provider) Interactive Voice Response
(IVR tip sheet/Enclosure)
July Update
-J-
Men’s Health: Cholesterol Management, Obesity
and Proper Nutrition, Immunization
Recommendations, and Colorectal and
Prostate Cancer Screenings
(Policy Update): Modifiers 26 and TC
June Update
July Update
-K-L-
More Information Regarding Claims Submissions
August Update
Laboratory Services Reminder
December Update
-M-
Multiple Services Billing Tip
February Update
-N-
(AmeriHealth 65) Medicare Changes for 2006
December Update
Medical Record Keeping Standards
February Update
(Changes in Drug Coverage with) Medicare Part D
Implementation
December Update
(“Do it All” with) NaviNetSM: A Tip to Streamline
the NaviNetSM Preauthorization Request Process
March Update
(“Do it All” with) NaviNetSM: Network Providers
Use NaviNetSM To Improve Efficiency and
Service to Patients
May Update
Medicare Part D offers new Benefits
November Update
(“Do it All” with) NaviNetSM: Preauthorization
Enhancements
February Update
Medicare Tiered Hospital Networks now available
for Members in AmeriHealth 65®Plus
November Update
December Update
(“Do it All” with) NaviNetSM: Streamline Daily
Administration
January Update
(New Benefits for AmeriHealth 65® Members)
Medicare Part D
October Update
(Clarification to) Member Benefits
December Update
(Printable Temporary) Member Identification
Information is Available Effective December 17,
2005
December Update
Member’s Health Update: Important Information
Regarding Colorectal Cancer Screening in DE
(Enclosure)
April Update
Member’s Health Update: Important Information
Regarding Colorectal Cancer Screening in NJ
(Enclosure)
April Update
(Delaware) Newborn Hearing Screening Mandate
December Update
New ConnectionsSM AccordantCareTM Program
Expands Disease Management for Members
with Chronic Diseases
New Diagnostic Imaging Services Improve
Radiology Testing for AmeriHealth
(Delaware Only)
April Update
May Update
June Update
New HMO Program in New Jersey: Individual
Preferred Plan
May Update
New Jersey Product Booklets: SEH HMO, SEH
HMO Plus, SEH POS, SEH POS Plus
(Enclosures)
July Update
Page 5 of 8
New Prescription Drug Benefit: Medicare Part D
July Update
(AmeriHealth) POS Plus Quick Reference Guide
(Enclosure)
March Update
New Products Effective 7/1/05: SEH HMO, SEH
HMO Plus, SEH POS, SEH POS Plus
July Update
(New) Prescription Drug Benefit: Medicare Part D
July Update
New Select Drug Program ® Copay Options for
New Jersey SEH and 51+ Members
May Update
(2005) Clinical Practice Guidelines Now Available
November Update
New Tr an saction s w ith A meri H ea lth: Y our Quick
Refer enc e to Billing , R eferra ls, a nd
E-Con nectivity Debuts
April Update
(Women’s Health Programs): National Breast
Cancer Awareness Month
(AmeriHealth and Its Affiliates) Pricing Procedure
for Unlisted or Not Otherwise Classified
(NOC) Services
January Update
New Features Available Via the Navinetsm
Provider Portal
December Update
Pricing Procedure for Unlisted or Not Otherwise
Classified (NOC) Services Fully Implemented
April Update
-O-
(Important Information About Prescription Drug
Coverage): Prior Authorization for Tarceva®
(erlotnib)
April Update
Obesity: A Growing Medical Concern
(Select Drug Program ® Formulary and)
Prescription Drug Prior Authorization Enclosure
October Update
Osteoporosis Prevention and Screening
-P-
(New) Products Effective 7/1/05: SEH HMO,
SEH HMO Plus, SEH POS, SEH POS Plus
July Update
Partners in Health 2004 Cumulative Index
January 2004 Update
(Enhanced Online) Provider Search to Include
Quality Information (Enclosure)
January Update
Passive Enrollment of Dual Eligibles into
AmeriHealth 65® (PA only)
October Update
November Update
December Update
(Enhanced) Provider Search Launching
this Spring
March Update
(New Features Included in) Pediatric
Growth Charts
Performing Provider ID, Group Provider ID,
and Tax ID Number Required in Order to
Ensure Clean Claims
April Update
Policy and Recommendations for the Use
of Menactra ®
Policy Update for Decavac™
Policy Update: Removal of Impacted Cerumen
April Update
Provider Supply Line: For Office Supplies and
Resources
May Update
December Update
Provider’s Role in Fighting Health
Insurance Fraud
January Update
Providers Required to Use NaviNetSM or
Telephonic Interactive Voice Response (IVR)
System to Obtain Member Eligibility Information,
Effective August 1, 2005
April Update
May Update
June Update
July Update
August Update
Page 6 of 8
Providers Required to Use NaviNetSM or
Telephonic Interactive Voice Response (IVR)
System to Obtain Member Eligibility Information
September Update
October Update
November Update
December Update
SEH POS Plus Product Booklet - NJ Only
(Enclosure)
July Update
Providing PHI to Employer Groups Acting as
Claims Fiduciaries
April Update
(Important Information About Prescription
Drug Coverage): Select Drug Program ®
Formulary Additions
February Update
(Changes To) PQAS and QPA 2007: Measurement
Year January through December 2006
December Update
-Q-
SEH POS Product Booklet - NJ Only
(Enclosure)
July Update
Select Drug Formulary Additions:
Byetta ® and Symlin®
August Update
(New) Select Drug Program® Copay Options for
New Jersey SEH and 51+ Members
May Update
-R(AmeriHealth Implementing) Radiology Quality
Initiative for Delaware Members Effective
August 1, 2005 (Delaware only)
July Update
Radiology Quality Initiative Grace Period ends
November 30, 2005
November Update
Radiology Quality Initiative Grace Period Ended
November 30, 2005
December Update
Select Drug Program® Formulary
June Update
(The) SMARTTM Registry: Your Practice’s Chronic
Condition Management Support Tool
May Update
Spacers for Metered Dose Inhalers Added As
Benefit Enhancement for AmeriHealth
(Delaware only)
May Update
(Removal of ) Referrals for Hemodialysis
December Update
Speech Pathology Transactions Revision
(Buckslip/Enclosure)
July Update
Restorative/Therapy Services Retrospective
Review
February Update
March Update
(Recommendations for Assessing and Managing
the) Suicidal Patient
RQI Postponement (Enclosure)
August Update
(New Effective Date For AmeriHealth Delaware)
Radiology Quality Initiative
September Update
-S-
Supporting Our Members, Your Patients:
January Update
February Update
March Update
April Update
July Update
August Update
September Update
October Update
SEH HMO Non-Plus Product Booklet - NJ Only
(Enclosure)
July Update
Surgical Team Documentation Form
December Update
SEH HMO Plus Product Booklet - NJ Only
(Enclosure)
July Update
Annual Synagis® (Palivizumab) Distribution
Program
September Update
Page 7 of 8
Synagis® (palivizumab) Shipment Dates for the
2004-2005 Respiratory Syncytial Virus
(RSV) Season
February Update
-T10-Digit Provider ID Number Required In Field 32
for CMS 1500 Forms Effective July 1, 2005
April Update
May Update
June Update
July Update
August Update
Third Party Liability Could Lead to
Claims Retractions
June Update
(New) 13-Position Member Identification Number
January Update
February Update
March Update
September Update
October Update
-W(Healthy Lifestyles Expands) Weight Mangement
Program
November Update
West Nile Virus
Women’s Health: Cervical Cancer Prevention
Women’s Health Programs: Clinical Breast
Examinations (CBEs) Are Essential to Breast
Cancer Prevention
-X-Y-Z-
(Important Reminder Regarding) Timely Claim
Filing Requirements
August Update
Tips for Effectively Using the ConnectionsSM
Health Management Program SMARTTM Registry
Transactions Buckslip (Enclosure)
July Update
(New) Transactions with AmeriHealth: Your
Quick Reference to Billing, Referrals, and EConnectivity Debuts
April Update
Treating Deep Vein Thrombosis with Low
Molecular Weight Heparin
-U(AmeriHealth New Jersey Contracts with Council
for Affordable Quality Healthcare for) Universal
Credentialing DataSource
September Update
October Update
-V-
Page 8 of 8

AmeriHealth PPO HSA-qualifi ed High Deductible Health Plans

Transcription

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