November Provider Digest

AmeriHealth Caritas North Carolina (ACNC) is committed to providing the support you deserve. You will find the following topics in this digest:

RESOURCES

TRAINING

Partnering with Providers to Impact Diabetes in North Carolina

North Carolina ranks 11th among states for the highest rates of diabetes in the nation*. AmeriHealth Caritas North Carolina (ACNC) is committed to the equitable improvement of health outcomes for members with diabetes.

The Hemoglobin A1c (HbA1c) blood test is a key tool used for optimal management of a diabetic individual's blood glucose levels. An HbA1c result greater than 9.0 is associated with increased risk of complications and death from diabetes. The North Carolina Department of Health and Human Services (NCDHHS) requires that all Prepaid Health Plans (PHPs) create and implement performance improvement projects (PIPs) aimed at impacting specific clinical focus areas including Diabetes HbA1c Poor Control > 9.0%.

ACNC's goal for the PIP is to improve the rate of HbA1c Poor Control among ACNC 's members ages 18 – 75 with diabetes, with particular attention to identifying, addressing, and eliminating inequities that lead to health disparities among marginalized populations. To improve the percentage of members with a poorly controlled or untested HbA1c, ACNC is:

  • Supporting optimal management and connection to resources for diabetic members with a recent HbA1c value > 9.0
  • Supporting care gap closure for diabetic members who have not had an HbA1c test in the last 12 months
  • Supporting providers to increase the submission of HbA1c level CPT-CAT-II codes
  • Collecting HbA1c results as supplemental clinical data

NOTE: Providers can access a list of patients with diabetes care gaps in the NaviNet portal via the PCP Performance Rollup Report found by clicking Report Inquiry and then Administrative Reports.

For more information regarding CPT-CAT-II codes specific to HbA1c levels that should be submitted via claims, please visit our 2022 HEDIS® Comprehensive Provider Education Tool found on NaviNet. If you have questions about how you can submit supplemental clinical data to ACNC, please contact your assigned ACNC Account Executive.

*Citation: [1] NC Health Information Exchange Authority. (2018). North Carolina Diabetes Registry: Data Management, Analytics, and Visualization (PDF).

Close Care Gaps by Mid-December

The deadline for Hybrid measure care gap closure for Measure Year 2022 via submission of the Care Gap Response Form in NaviNet is December 15, 2022, to allow for processing and capture before December 31, 2022.

NaviNet users can find instructions on how to close care gaps on the NaviNet homepage, under Tools for Quality Outcomes. Then open the Care Gaps Response Form Provider Guide (PDF). This same guide is also found on our website. If you have questions about NaviNet or where to find these tools, please reach out to ACNC's Value-Based Program Manager, Elice Graham for support.

Paper Claims Submission Error Resolved

ACNC has determined that some paper claims submitted between mid-August and mid-September 2022 may have been rejected as invalid due to a file import malfunction with our vendor. The issue has been resolved, and a monitoring process has been implemented. If you received a denial letter stating that a patient's identity could not be determined, please resubmit the claim to ACNC for reprocessing or call Provider Claim Services at 1-888-738-0004 and provide the claim reference number located on the denial letter.

Childhood Health and Wellness Clinical Leadership Forum

AmeriHealth Caritas North Carolina (ACNC) is pleased to provide an opportunity for providers to engage with our team to exchange best practices related to Quality and Population Health outcomes. We invite you to join us for a zoom webinar on Wednesday, December 14, 2022, from Noon – 1:00 p.m.

Topics include:

  • Quality Measures Overview
  • Care Gap Closure Efforts
  • Early Periodic Screening, Diagnostic and Treatment (EPSDT) Resources
  • Primary Care Physician Quality Enhancement Program (PCP QEP) Resources
  • Best Practice Spotlight
  • Round of Q&A

Please register for the Childhood Health and Wellness Clinical Leadership Forum on Wednesday, December 14, 2022, from Noon – 1 p.m.

RESOURCES

Updated Provider Manual Now Available

The updated Provider Manual (PDF) is available on our website. Several high-level revisions include:

  • Updated language to reflect current business practices
  • Updated time and distance, and definition charts per NCDHHS
  • High dollar post-payment reviews process
  • 275 claims attachment process
  • Where to find the Known System Issues tracker
  • Contact information for different departments

For your convenience, a Revision Log is posted along with the Provider Manual to help identify updates.

Our Claims and Billing Manual (PDF) has also recently been updated. It contains new ZZ Qualifier provider taxonomy language, high dollar pre-payment and post-payment reviews information and 275 medical attachments process additions.

Outpatient Behavioral Health Prior Authorizations Limitations Removed

ACNC has removed the prior authorization limitations for the outpatient behavioral health psychotherapy codes listed below. ACNC will continue to monitor over or under utilization of behavioral health psychotherapy services for our members.

The outpatient behavioral health psychotherapy CPT codes are:

90785

90791

90832

90846

90853

 

90792

90833

90847

 

 

 

90834

90849

 

 

 

90836

 

 

 

 

90837

 

 

 

 

90838

 

 

New North Carolina Department of Health and Human Services (NCDHHS) Incident Response Improvement System (IRIS) Website Link

IRIS sites are transitioning to the NCDHHS.gov website. NCDHHS moved the IRIS Training site in November to https://iris.ncdhhs.gov. All IRIS users should bookmark the updated live site before December 31, 2022, to ensure easy access.

Durable Medical Equipment (DME) Billing Guidance

Historically, North Carolina Medicaid/NCDHHS has utilized a series of local codes for certain Durable Medical Equipment (DME). In 2020, regions went live with the migration of NC Medicaid submissions to the state becoming submissions to the PHPs. DME is billed via HIPAA-compliant national Healthcare Common Procedure Coding System (HCPCS) codes.

DME providers billing North Carolina Medicaid member submissions are required to bill the appropriate national HCPCS code electronically via 837P on the professional service (SV1) segment in element location SV101-2. Billing guidelines permit only one HCPCS code per service line on an 837P electronic submission. To read more and see a codes grid, visit our Newsletter and Updates webpage.

Preferred Drug List (PDL) Updates

North Carolina Medicaid and NC Health Choice PDL updates were effective on October 1, 2022. The new form updates include Opioid Dependence, Topical Local Anesthetics and Synagis. Visit the ACNC Pharmacy website to download the updated PDL.

Help Members Prepare for the End of the Federal Public Health Emergency

In preparation for the end of the national Public Health Emergency (PHE), NCDHHS wants to help beneficiaries, providers and community stakeholders understand potential impacts and steps they can take to be ready. Visit NCDHHS website for resources and a communications toolkit for community partners who work closely with beneficiaries. See the NCDHHS Special Bulletin #263 for additional information.

TRAINING

New Early Periodic Screening, Diagnostic and Treatment (EPSDT) Virtual Training

Yalanda Thomas Join presenter, Yalanda Thomas, an EPSDT Manager with AmeriHealth Caritas Family of Companies who will orient attendees on the Oral Health Periodicity Schedule, patient screening visits, referral requirements and more.

Register here for this informative presentation on December 8, 2022, from Noon to 1 p.m. ET, or visit our Featured Trainings page for more information.

New Navinet Solution for Online Prior Authorizations Is Coming Soon

ACNC has worked with NantHealth | NaviNet to bring you Medical Authorizations, a robust, intuitive and streamlined online authorizations workflow in 2023.

In addition to submitting and inquiring on existing authorizations, you will also be able to:

  • Verify if no authorization is required.
  • Receive auto approvals in some circumstances.
  • Submit amended authorizations.
  • Attach supplemental documentation.
  • Sign up for in-app status change notifications directly from the health plan.
  • Access a multi-payer authorization log.
  • Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities. (Fax is no longer required.)
  • Review inpatient admission notifications and provide supporting clinical documentation.

Want to learn more about Medical Authorizations? Video tutorials and step-by-step instructions will be available via the NaviNet Plan Central page and the NantHealth Help Center. ACNC will offer training on the new system in 2023.

Collaborative Care Model (CoCM) Training Series

The North Carolina Department of Health and Human Services (NCDHHS) has partnered with NC AHEC to provide educational and practice-based support to primary care practices interested in implementing the Collaborative Care Model (CoCM) — a team-based, interdisciplinary approach to deliver evidence-based diagnoses, treatment, and follow-up care for patients with mild to moderate behavioral health needs.

The CoCM Training Series includes the following objectives:

  • Describe the principles of Collaborative Care.
  • Identify key concepts and care roles of effective implementation of Collaborative Care.
  • Explain the use of and evidence for measurement-based care.

The 10-module series will be released monthly and will provide you with the initial steps to implement CoCM and the tools for ongoing support. Contact hours, CEUs, NASW-NC Contact Hours, AMA PRA Category 1 Credit™, and NBCC will be offered. Module 1: Collaborative Care Model (CoCM) Rationale and Evidence, is now available.

Register now for this module in the training series.

Providers