2021 Provider Notifications

This edition covers topics such as 2021-2022 flu vaccinations, COVID-19 news and updates, what is covered and what is not covered by AmeriHealth Caritas Pennsylvania, timely filing reminder, and changes to the statewide preferred drug list (PDL).

AmeriHealth Caritas Pennsylvania will temporarily waive prior authorization for patient transfers from inpatient hospitals to other skilled levels of care.

The Pennsylvania Department of Human Services (DHS) will implement changes to the statewide preferred drug list (PDL) on January 3, 2022.

Members currently receiving more than the quantity limit for whom it is not medically advisable to change therapy will require prior authorization before January 3, 2022.

Use these tips to help ensure timely and accurate processing of your prior authorization requests.

Updates include updated Services Requiring Prior Authorization and added information about the Prior Authorization look-up tool on the Provider website, clarified Home Modifications not covered, information regarding Home Accessibility DME coverage, and more.

AmeriHealth Caritas Pennsylvania is following the guidelines outlined in the Pennsylvania Department of Human Services (DHS) Medical Assistance Bulletin (MAB) 08-21-07 regarding the procedure for submitting claims for a take-home supply of naloxone.

In preparation for the onset of the 2021-2022 flu season, while still facing COVID-19, we are asking you to encourage your patients to get their flu shot.

New Condition Optimization Prospective Outreach Program Training dates are available.

Beginning December 8, 2021, AmeriHealth Caritas Pennsylvania will implement AmeriHealth Caritas COMPASS℠, a referral optimization initiative that will give referring Primary Care Providers (PCPs) information about specialists’ performance as measured by established and objective quality and efficiency performance measures.

Beginning December 8, 2021, AmeriHealth Caritas Pennsylvania will implement AmeriHealth Caritas COMPASS℠, a referral optimization initiative that will give referring Primary Care Providers (PCPs) information about specialists’ performance as measured by established and objective quality and efficiency performance measures.

Additional products will have a quantity limit on the AmeriHealth Caritas Pennsylvania drug formulary.

AmeriHealth Caritas Pennsylvania is following the Department of Human Services (DHS) recently published limitations for electric breast pumps. These outlined changes will be effective December 15, 2021.

AmeriHealth Caritas Pennsylvania providers are now able to access all practice locations under a specific Tax ID Number (TIN) once registered for NaviNet.

Important updates include an additional item under Invalid Electronic Claim Records, WebConnect replacing Connect Center, an updated Rendering Provider ID section, and more.

Tips to help improve your quality ratings, including guidance on chlamydia screening in women and immunizations for adolescents.

Effective November 15, 2021, when a definitive drug testing code and a presumptive drug testing code by instrumented chemistry analyzers (80307) are reported on the same date of service for the same member by the same independent clinical laboratory, AmeriHealth Caritas Pennsylvania will only reimburse for the presumptive test.

AmeriHealth Caritas Pennsylvania will follow the guidelines recently released by the Pennsylvania Department of Human Services (DHS) Medical Assistance (MA) Bulletin (MAB) 01-21-08 regarding expanding the scope of MA enrolled providers who may bill for administration of the novel coronavirus (SARS-CoV-2) vaccines and monoclonal antibody therapy.

AmeriHealth Caritas Pennsylvania will follow the guidelines recently released by the Pennsylvania Department of Human Services (DHS) regarding the administration and payment of the SARS-CoV-2 vaccine for homebound members.

AmeriHealth Caritas Pennsylvania follows Pennsylvania Medical Assistance guidelines for ambulance mileage reimbursement for all ambulance providers.

Effective October 1, 2021, AmeriHealth Caritas Pennsylvania will change the reimbursement for HCPCS code A4256.

Some products will be removed from the AmeriHealth Caritas Pennsylvania drug formulary. Members currently receiving these products will require a new prescription for an alternative product before September 13, 2021.

As outlined in the AmeriHealth Caritas Pennsylvania Claims Filing Guide, not following claims submission deadlines will result in a denied claim.

AmeriHealth Caritas Pennsylvania is pleased to announce the availability of the second edition of our provider newsletter, Connections.

We are introducing this program to streamline the submission of information to AmeriHealth Caritas Pennsylvania.

As announced on May 1, 2021, effective July 1, 2021 AmeriHealth Caritas Pennsylvania will only accept ONAF forms that are submitted through the Optum website.

Anticipated in the third quarter 2021, AmeriHealth Caritas Pennsylvania is launching a “Prospective Outreach Program” to encourage PCPs to proactively reach out and schedule routine office visits for patients who might be due for routine care.

Beginning in June 2021, the PCP information is being removed from the AmeriHealth Caritas Pennsylvania member ID cards.

Additional webinar offerings to help familiarize your practice with the upgraded version of Jiva are available.

AmeriHealth Caritas Pennsylvania strongly reminds providers that all payments made to providers under the MA program plus any copayment required to be paid by a recipient shall constitute full reimbursement to the provider for covered services rendered. Further, a provider who seeks or accepts supplementary payment of another kind from DHS, the recipient or another person for a compensable service or item is required to return the supplementary payment.

Effective August 1, 2021, prior authorization is required for all home oxygen rentals, regardless of monthly cost.

Effective for dates of services on and after August 1, 2021, AmeriHealth Caritas Pennsylvania will follow the guidelines outlined by the Department of Human Services (DHS) recently released Medical Assistance Bulletin (MAB 99-21-03).

Effective July 1, 2021, prescriptions written for a drug that has the same or highly similar mechanism of action as another drug will be subject to therapeutic duplication requirements and/or safety edits per the PA PDL prior authorization guidelines.

Review a list of HCPCS codes undergoing updates to align medical claim configuration with drug formulary and prior authorization reference resources.