2022 Provider Notifications

Highlights include 2022 – 23 flu vaccinations, DHS-issued changes to the statewide preferred drug list (PDL) effective January 9, 2023, and more.

As a reminder, the standard 2012 American Dental Association (ADA) claim form that accompanies the BLE form must include a diagnosis code.

The Pennsylvania Department of Human Services (DHS) will implement changes to the statewide preferred drug list (PDL) on January 9, 2023.

Providers should use these recommendations when billing for IP claims when an AmeriHealth Caritas Pennsylvania member has Medicare Part A and B, but Medicare Part A has exhausted, or the member has Medicare Part B only.

Effective November 21, 2022, AmeriHealth Caritas Pennsylvania is implementing a new system for providers to submit prior authorization requests for medical and behavioral health services.

Before billing AmeriHealth Caritas Pennsylvania when there is a primary insurer, providers are required to bill the primary insurer first and obtain an Explanation of Benefits statement from the primary insurer.

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

AmeriHealth Caritas Pennsylvania is following guidelines outlined in Medical Assistance Bulletin (MAB) 08-22-19 around submitting claims for a take-home supply of naloxone.

Effective on and after August 29, 2022, AmeriHealth Caritas Pennsylvania providers should utilize the codes and the fee schedule for adult vaccines as outlined in Medical Assistance bulletin 01-22-42.

Effective November 30, 2022, care management and utilization management services for members admitted to the NICU or special care nursery will be coordinated and provided by and through the AmeriHealth Caritas PA care management team and Neonatal Care Coordination program.

Effective December 1, 2022, AmeriHealth Caritas Pennsylvania will reinstate the prior authorization requirements for existing shift care services provided to members under the age of 21.

AmeriHealth Caritas Pennsylvania has partnered with the March of Dimes to provide a webinar on implicit bias.

Beginning October 15, 2022, AmeriHealth Caritas Pennsylvania will require providers to follow standard published coding guidelines which include the use of the appropriate anatomical modifier.

AmeriHealth Caritas Pennsylvania will follow the guidelines issued on July 26, 2022, by the Department of Human Services (DHS) Medical Assistance Bulletin (MAB) 01-22-41 outlining the addition of newly created Current Procedural Terminology (CPT) codes for monkeypox laboratory testing and vaccines.

Quest Diagnostics is the preferred in-network independent lab provider for AmeriHealth Caritas Pennsylvania. However, a provider may also use a participating in-network hospital outpatient laboratory for lab testing services.

Updates and topics include dental services covered when medically necessary, how to approach missed appointments, updated language around retrospective review, and more.

Please refer to this reminder about which home accessibility DME services are covered by AmeriHealth Caritas Pennsylvania and which ones require prior authorization.

Over 400,000 individuals (statewide) did not select a new MCO. DHS auto-assigned them to one of the PH MCO plans available to them in their specific zone. Therefore, there is a chance that a member could have been assigned to another PH MCO through the revised DHS auto-assignment process.

If an AmeriHealth Caritas Pennsylvania member comes to your office without an ID card, please do not turn them away for service. Check their eligibility by either calling the AmeriHealth Caritas Pennsylvania automated IVR system (1-800-521-6007) or through the NaviNet eligibility search.

Prior authorization is required for septoplasty, submucous sesection (CPT code 30520).

Starting in the month of August, you will see new remark codes on your Explanation of Benefits (EOBs).

Providers who believe their patients would benefit from an automatic blood pressure monitor (A4670) should give them a prescription that can be taken to any participating network pharmacy.

Highlights include: 2022 updated Provider Manual is now available online, 2022 HCBS Provider Claims Filing Instructions are now available online, and more.

The blood lead reference value for children is being updated from 5 μg/dL to 3.5 μg/dL

Updates and changes include: update to notification process following a pharmacy prior authorization denial, updated language around complaints, grievances and fair hearings, changes to the paper credentialing application process, and more.

The 2022 recommended immunization schedule for children and adolescents age 18 years or younger can be found in the Department of Human Services (DHS) Medical Assistance Bulletin (MAB) 99-22-03.

A claim can be submitted once authorization is approved with no need to hold the claim for the NFCE determination.

Effective September 1, 2022, the Pennsylvania Department of Human Services is changing which physical health managed care organizations are available for Medical Assistance consumers.

The June 3, 2022, launch of the new prior authorization system is delayed. Information regarding a new launch date will be communicated at a later date.

Effective August 1, 2022, the AmeriHealth Caritas Pennsylvania adult immunizations/immune globulin fee schedule will be updated.

All network providers must complete and attest to completion of mandatory FWA training on an annual basis, as required by our contract with the Pennsylvania Department of Human Services (DHS).

Coverage policy reminder for nursing facilities.

Some products will be removed from the AmeriHealth Caritas Pennsylvania drug formulary on June 15, 2022. Members currently receiving those products will require a new prescription for an alternative product before that date.

AmeriHealth Caritas Pennsylvania is pleased to announce the availability of the 2022 medical provider claims filing instructions.

Effective June 3, 2022, a new system is being implemented for providers to submit prior authorization requests for medical and behavioral health services.

AmeriHealth Caritas Pennsylvania will follow the Department of Human Services (DHS) guidelines released in Medical Assistance Bulletin (MAB) 25-21-01 regarding the coverage of home accessibility durable medical equipment and procedure for obtaining an 1150 administrative waiver in the fee-for-service delivery system.

Effective April 1, 2022, AmeriHealth Caritas Pennsylvania is revising the reduced payment policy for certain Evaluation and Management (E/M) procedure codes billed with Common Procedure Terminology (CPT) modifier 25 when services occur within the minor procedure Global Surgery time frames as defined by the Centers for Medicare & Medicaid Services (CMS).

Highlights include a new Medical Assistance bulletin (MAB) announcing newly created Current Procedural Terminology (CPT) codes for the administration of SARS-CoV-2 vaccines, claims filing instructions, and more.

The 2022 Quality Enhancement Program (QEP) manual is now available for our primary care providers.

AmeriHealth Caritas Pennsylvania will follow the Pennsylvania Department of Human Services (DHS) guidelines and will implement the new procedure code T1019 for reporting EVV PCS services for 15-minute units.

Effective April 1, 2022, AmeriHealth Caritas Pennsylvania is upgrading the NaviNet portal to enhance the Retrospective and Prospective Outreach Programs.

AmeriHealth Caritas Pennsylvania will follow the guidelines issued in MAB 01-21-51 addressing CPT codes for the administration of pediatric SARS-CoV-2 Pfizer, Inc. vaccine. Additionally, we are also following guidelines issued in MAB 01-21-55, outlining CPT codes for the administration of booster doses of the SARS-CoV-2 vaccines.

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 February 1, 2022.