December Provider Digest
AmeriHealth Caritas North Carolina (ACNC) is committed to providing the support you deserve. A Known System Issues Tracker is updated weekly and also available in NaviNet to providers.
You will find the following topics in this December digest:
- Provider Support and Stabilization Following Hurricane Helene
- Save the Date for Lunch with Us in Greensboro
- Issue 3 of Connections Is Now Available
- Value-based Programs Include Medicaid Expansion Members
QUALITY CORNER
- Providing Care for Patients Prescribed Antipsychotic Medications
- Medical Record Data Request for Select Providers
MEMBER SPOTLIGHT
CLAIMS AND BILLING
FORUMS AND SURVEYS
Provider Support and Stabilization Following Hurricane Helene
In October, ACNC launched a Hurricane Helene Disaster Recovery webpage with frequent updates and developed a new protocol offering provider stabilization payments to providers in the disaster region that had treated and billed claims for ACNC members in the last 12 months. If your practice needs financial support, complete this one-time application no later than January 16, 2025.
Working collaboratively with other prepaid health plans and the North Carolina Department of Health and Human Services (NCDHHS), worked quickly to respond to the wide-ranging impact of the storm on our provider community in the 28 disaster-declared counties, including the Eastern Band of Cherokee Indian territory. ACNC’s initial efforts were concentrated on member outreach, especially to those with high-risk medical conditions, pregnant women and newborns. Data reported by the NC Medical Society indicated that as many as 17% of practices in the region were unable to reopen due to damage and that nearly a quarter of all providers had significant concerns about meeting financial obligations.
In response, we quickly took numerous steps to ease financial and administrative pressures on providers, including stopping payment recoveries, medical records requests, prepayment edits and high dollar claim inquiries to support provider cash flow. Our Utilization Management team enlisted additional support to ensure timely authorizations and supported Care Management in finding alternative providers for members as needed.
As of December 17, ACNC has made $5.06 million in stabilization payments to 1,163 providers located in western North Carolina. For more disaster recovery information, read the NC DHHS blog post from December 12, 2024.
Save the Date for Lunch with Us in Greensboro
Beginning in 2025, the Provider Network Management team will be traveling across the state to meet with our network providers and office staff. This is a time for us to get to know you better and determine the best ways to work together to serve our shared members’. On Thursday, January 30, 2025, from noon to 3 p.m., we will be hosting provider practices in region 2 for lunch and an information session. If you are interested in attending, please contact your dedicated Account Executive directly or via the Region 2 email address.
Issue 3 of Connections Is Now Available
This issue contains articles and interviews on the following topics, and more:
- Cultural competency
- Best practices for improving perinatal care
- Helpful tips for keeping your provider profile current in NCTracks
- Top provider care-gap closure results
- Resources on our Bright Start® program
- Member Wellness and Opportunity Centers offering multiple meet-and-greet opportunities with our team
If you would like a printed copy of the 2024 magazine as a resource, please send your request along with mailing address information to your Provider Network Management Account Executive.
Value-based Programs Include Medicaid Expansion Members
ACNC’s value-based programs offer incentives for high-quality and cost-effective care, member service and convenience, and health data submission. As communicated on August 16, 2024, due to the addition of Medicaid expansion members to our panels, which began December 1, 2023, the North Carolina Department of Health and Human Services (NCDHHS) has required ACNC and the other prepaid health plans to include expansion member data in our performance metrics.
Please visit the NaviNet provider portal webpage to learn about the benefits of the portal. Continuing with the December 2024 reports, practice performance scorecards available in NaviNet include two results:
- Metric including the Medicaid expansion population.
- Metric excluding the Medicaid expansion population.
There will be no changes to 2024 performance targets or incentive calculation methodology. ACNC will use the metric result that is the most beneficial to provider performance when determining your practice’s quality performance incentive payment.
We encourage you to use this information to become familiar with how this new population is interacting with the health care delivery system in anticipation of incorporating this population into performance determination in the future.
Providing Care for Patients Prescribed Antipsychotic Medications
Antipsychotic medications help patients with certain behavioral health conditions and disorders, but these medications can have serious side effects. Three specific HEDIS measures focus on antipsychotic medications with the aim of reducing and controlling symptoms while keeping side-effects at a minimum . These measures are outlined below. The medication groupings for these measures include phenothiazine antipsychotics, thioxanthene, long-acting injections, miscellaneous antipsychotic agents, and psychotherapeutic combinations.
Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)
The “Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics” measure encompasses the number of children/adolescents ages 1 – 17 years who had a new prescription for an antipsychotic medication and had documented psychosocial care as first-line treatment .
Patients should engage in psychosocial care 90 days prior to the initial prescription and up to 30 days after the initial prescription.
Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)
The “Metabolic Monitoring for Children and Adolescents on Antipsychotics” measure indicates the number of children/adolescents ages 1 – 17 years who had two or more antipsychotic prescriptions and had received blood glucose testing and cholesterol testing during the year2.
Once prescribed an antipsychotic medication or a combination of different antipsychotic medications for the second time, it is necessary for the patient to have their blood glucose and cholesterol checked.
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
The “Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications” measure is the number of members ages 18 – 64 years with schizophrenia, schizoaffective disorder or bipolar disorder who received an antipsychotic medication and completed a diabetes screening test2.
10 best practices for measures specific to antipsychotic medications
| 1 | “For new child/adolescent patients taking antipsychotic medications, complete a thorough evaluation and coordination with” the patient’s behavioral health professional “to ensure that all medications are addressing current symptoms for the patient's continued stability and recovery.”3 |
| 2 | Provide education to patients and caregivers “about the risks associated with antipsychotic medications and cardiovascular disease” and diabetes “and about the importance of a healthy lifestyle.”4 |
| 3 | “Ensure patient schedules appropriate lab screenings,”4 and “document lab results and any action that may be required.”5 |
| 4 | “Routinely refer members on an antipsychotic medication… to have their blood glucose or HbA1c, LDL-C or cholesterol drawn at least annually.”5 |
| 5 | “Document” the “patient’s response to medication.”5 |
| 6 | “Establish a baseline and continuously monitor and manage side-effects of antipsychotic medication therapy.”3 |
| 7 | “Periodically review the ongoing need for continued therapy with antipsychotic medications.”3 |
| 8 | “Monitor children on antipsychotic medications for metabolic health complications such as weight gain and diabetes.”5 |
| 9 | “Follow up with” the “patient’s parents or guardians to discuss… lab results” and provide education.4 |
| 10 | Closely “monitor female children/adolescents treated with certain antipsychotics as they may also be at increased risk for gynecological problems.”3 |
1 “Antipsychotic Medications,” The Centre for Addiction and Mental Health, https://www.camh.ca/
2 “North Carolina’s Medicaid Quality Measurement Technical Specifications Manual Measurement: Year 2024: Version 2024.0,” North Carolina Department of Health and Human Services, January 30, 2024, https://medicaid.ncdhhs.gov/
3 “Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP),” Horizon Blue Cross Blue Shield of New Jersey, https://www.horizonblue.com/
4 “MY2023 HEDIS® Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) Measure: Provider Tip Sheet,” Carelon Behavioral Health, April 2023, https://www.carelonbehavioralhealth.com/
Medical Record Data Request for Select Providers
The annual HEDIS reporting period is just around the corner, and we need provider cooperation with our efforts to collect medical record data for our members whom you have treated.
AmeriHealth Caritas North Carolina has contracted with Reveleer to manage the medical record retrieval for the annual medical record review process. Reveleer is required to comply with Health Insurance Portability and Accountability Act (HIPAA) Privacy requirements throughout the retrieval process and is trained in medical record retrieval for HEDIS, Centers for Medicare & Medicaid Services (CMS), and state quality reporting programs.
Disclosure and use of the medical records, and the collection of medical records for this purpose, are considered to be treatment, payment or health care operations in accordance with the HIPAA Privacy Rule (see 45 C.F.R. §164.502 (a)(1)(ii)).
We appreciate your cooperation in working with Reveleer to schedule retrieval of any requested member records. Records requested should be provided at no charge to the health plan.
If you have any questions, please reach out to Theresa Smith, Lead Data Reviewer, at 484-423-3149. We greatly appreciate your cooperation and timely assistance with this medical record request.
Transportation for ACNC Members
“Transportation is a critical factor contributing to missed medical appointments. According to the American Hospital Association, approximately 3.6 million people in the United States do not obtain medical care due to transportation issues.”1 AmeriHealth Caritas North Carolina can arrange and pay for transportation to help members get to and from their appointments for Medicaid-covered care. We also provide transportation to educational programming and events at our Wellness & Opportunity Centers. This service is at no cost to the member.
Members can call ACNC Member Services for help in making an appointment or use the ModivCare Mobile app. ACNC also provides reimbursement at current IRS rates for members who use their own car or have a caregiver, family member or friend drive them to an appointment. Find more details about ACNC’s Transportation benefit on our website and please share with our members.
1 TransLoc, Inc., “The Cost of Missed Medical Appointments: A Hidden Burden on Healthcare, August 29, 2024, https://transloc.com/
Plan Privacy and Security Procedures Reminder
AmeriHealth Caritas North Carolina complies with all federal and North Carolina regulations regarding member privacy and data security, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Standards for Privacy of Individually Identifiable Health Information as outlined in 45 CFR Parts 160 & 164. All member health and enrollment information is used, disseminated and stored according to plan policies and guidelines to ensure its security, confidentiality and proper use.
As an AmeriHealth Caritas North Carolina provider, you are expected to be familiar with your responsibilities under HIPAA and 42 CFR, Part 2, which governs the confidentiality of alcohol and drug treatment information, and to take all necessary actions to fully comply. AmeriHealth Caritas North Carolina providers are required to take the following steps:
- Protect all personally identifiable information (PII) and protected health information (PHI) received from the plan.
- Ensure the secure destruction of PII/PHI received in error.
- Assist with privacy and security investigations.
- Provide ACNC with attestations of destruction in a timely manner.
- Never make copies or further disclose any information received in error.
Telehealth Claims. Paid Right. The First Time.
To bill properly, telehealth service providers are encouraged to follow guidance listed inside Clinical Coverage Policy (CCP) 1H – Telehealth, Virtual Communications and Remote Patient Monitoring. To help ensure claims are paid right, the first time, review the following tips:
- “Telehealth, virtual communication, and remote patient monitoring claims should be filed with the provider’s usual place of service code(s) and not place of service (POS) 02 (Telehealth).” The one exception is when a home visit utilizes telehealth. This service is considered Hybrid telehealth and “should be filed with place of service (POS) 12 (Home).”6
- “Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier should not be used for virtual patient communications (including telephonic evaluation and management services) or remote patient monitoring.”
1 NC Medicaid Telehealth, Virtual Communications and Remote Patient Monitoring: Medicaid Clinical Coverage Policy No: 1H, Amended Date: June 1, 2023
Quarterly Webinar Series for Behavioral Health Providers
The ACNC Behavioral Health Provider Network Management team invites you to join a virtual forum to engage with plan leadership to discuss operational and administrative activities. The goal of our time is to get to know each other, share tips and tricks to make your job easier and ultimately work together to improve behavioral health outcomes for our members. Each lunchtime session will include important information related to credentialing, care management, HEDIS priorities, billing functions and more. We will also offer a Provider Spotlight to highlight best practices and encourage patient collaboration.
Register for just one or the entire series.
Each session is from noon to 1 p.m. ET.
- Thursday, January 9, 2025
- Thursday, April 10, 2025
- Thursday, July 10, 2025
- Thursday, October 9, 2025
Join Us in 2025
Please join us for upcoming provider training and networking opportunities, including a new Behavioral Health webinar series, quarterly Clinical Leadership Forums and monthly provider orientations. Visit the provider training webpage for dates, times and registration links.