January Provider Digest

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

• Updated Provider Manual Now Available
• 2024 PerformPlus^® True Care Programs Launch
• Prior Authorization Requirement Changes for Select Procedures
• Home Health Electronic Visit Verification Reminder

QUALITY CORNER

• Childhood Immunization (CIS) Combo 10 HEDIS^® Measure
• Regional Baby Showers Continue in 2024

PHARMACY

• ACNC Upcoming Pharmacy Changes
• Discontinuation of Flovent HFA and Flovent Diskus
• Discontinuation of Levemir

CLAIMS AND BILLING GUIDANCE

• Tips to Prevent Claims Denials and Receive Faster Payment

MEMBER BENEFIT SPOTLIGHT

• Members Earn $25 for Completing a Care Needs Screening

TRAININGS AND FORUMS

• Let’s Work Together: Provider Orientation
• NEW Electronic Funds Transfer Enrollment Link
• 2024 Clinical Leadership Forums

Updated Provider Manual Now Available

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

• Updated member CARE Card rewards
• Reorganized prior authorizations content and submission process for clarity
• Simplified provider grievance and appeals process information
• DHHS Credentialing and Recredentialing updates
• DHHS Tobacco Free Policy information — effective April 1, 2024

For your convenience, a revision log is found at the back of the Provider Manual to help identify updates.

2024 PerformPlus^® True Care Programs Launch

Manuals and measures for AmeriHealth Caritas North Carolina’s (ACNC) 2024 enhanced incentive programs for selected providers have been posted to the Value-Based Programs page on our website. The PerformPlus True Care Programs are reimbursement systems developed for participating practitioners to deliver quality, cost-effective and timely care to our members. These programs suggest opportunities for providers to enhance revenue while providing quality and cost-effective care.

The 2024 programs include:

1. Maternity Care Providers
2. Behavioral Health Providers
3. Primary Care Providers
4. Maternity Care Incentive Program
5. Gaps in Care Closure Incentive Program

Please join Practice Transformation Director, Pinkey Slade, for one of the following training opportunities to learn more about these enhancement programs. Click a date below to register.

Prior Authorization Requirement Changes for Select Procedures

Our goal is to make it easier for providers to navigate the prior authorization process and help ensure timely member access to necessary services. Removal of prior authorization for certain services is part of our continued efforts to make the process more efficient and transparent.

Beginning March 18, 2024, the procedure codes in Table 1 do not require prior authorization.

Prior authorization is required for the codes listed in Table 2.

To verify whether any service requires prior authorization, use the Prior Authorization Lookup Tool. Remember, you can save time by submitting your medical authorizations electronically via NaviNet. Please contact Provider Services at 1-888-738-0004 for additional information or support.

Home Health Electronic Visit Verification Reminder

Per guidance from the NCDHHS, Electronic Verification Visit (EVV) for Home Health Care Services (HHCS) providers is required.

Per guidance from the NCDHHS, home health care services (HHCS) providers who provide home health aide services, physical therapy, occupational therapy, speech therapy and skilled nursing visits are required to implement the electronic visit verification (EVV) system.

All Home Health EVV claim information for ACNC members must be submitted through HHAeXchange.

For more information, visit the NCDHHS EVV webpage.

• Register with HHAeXchange.
• Home Health Portal Demo Training through HHAeXchange (PDF)
• HHAeXchange Support Email
• HHAeXchange Mobile App Demo (Video)

Prior authorization is now required following the member’s 18th home health visit by any home health provider (across all disciplines) in a calendar year. Any home health visit, in any discipline, after the 18th must be authorized.

Home health services include:

• Home health aide services
• Home health speech therapy
• Home health occupational therapy
• Home health physical therapy
• Private duty nursing
• Home health social worker visits
• Home health direct skilled nursing services

Request authorization for home health services from ACNC Utilization Management, 24 hours a day, seven days a week. Please refer to the Prior Authorizations webpage for additional information.

Childhood Immunization (CIS) Combo 10 HEDIS^® Measure

Childhood Immunization (CIS) Combo 10 HEDIS measure is the percentage of children who have received the required combination of 10 vaccines by their 2nd birthday. View the Combo 10 series requirements.

Best practices to meet the Childhood Immunization (CIS) Combo 10 measure include:

• Checking for missing vaccinations at each visit
• Providing after-hours appointments
• Sending reminders by text, mail or phone
• Scheduling outreach to members with upcoming birthdays who are non-compliant with vaccines

ACNC is offering a $50 CARE Card reward for children ages 2 and younger who receive a flu shot to help encourage vaccinations in young children.

All vaccines should be documented in North Carolina Immunization Registry (NCIR). The initial HepB vaccine given in the hospital at birth should also be documented in NCIR. When managing new patients from out of state, all previous vaccinations received should be documented in NCIR.

ACNC would like to partner with providers to host vaccine events. If you are interested, please contact ACNC Quality Management by email at acncqualitymanagement@amerihealthcaritas.com.

Regional Baby Showers Continue in 2024

In 2024, ACNC will continue working to improve maternal health outcomes, especially among people of color, by hosting quarterly regional community baby showers around the state. Our Quality Team has partnered with our Wellness & Opportunity Centers and numerous community partners to host events in every region to educate, empower and support women who have recently delivered a baby or who are pregnant, as well as their families.

Along with our transportation vendor, Modivcare, we invite local stakeholders to participate wrapping these expecting families with community support.

Through the baby showers, we hope to:

1. Improve birth outcomes.
2. Encourage member engagement in the Bright Start^® care management program.
3. Increase member and family use of Wellness & Opportunity Centers for ongoing education and support.
4. Encourage members to receive prenatal and postpartum care.
5. Offer opportunities to learn about child vaccinations and well-child visits.

Our baby showers offer us a chance to celebrate the arrival of these new babies and to encourage moms to get the prenatal and postpartum care they need. In 2023, we offered dietary and general health information, early childhood development and education tips, and information about immunizations and wellness checks. We also shared discussions around breastfeeding, sleep and car seat safety.

ACNC Pharmacy Upcoming Changes

• Pharmacy Prior Authorization Criteria and Form changes to be updated in 2024.
• NC Medicaid Preferred Drug List update will occur April 1, 2024.
• See discontinuation of medications article below.

For assistance with pharmacy prior authorizations or pharmacy claim questions, contact PerformRx Provider Services at 1-866-885-1406.

Discontinuation of Medications

For complete details, please reference the NC Medicaid Pharmacy Newsletter, December 2023.

Flovent HFA and Flovent Diskus

As of December 31, 2023, GSK has discontinued all strengths of Flovent HFA and Flovent Diskus. The authorized generics, fluticasone propionate HFA (generic for Flovent HFA) and fluticasone propionate diskus (generic for Flovent Diskus), have been added as preferred on the NC Medicaid Preferred Drug List (PDL) effective December 1, 2023.

Flovent HFA/Diskus will remain preferred so that claims will continue to pay until any remaining stock of the brand is depleted.

Levemir

Novo Nordisk has announced the permanent discontinuation of all formulations of Levemir^®. Supply disruptions of Levemir FlexPen^® are expected to begin in mid-January 2024, followed by the complete discontinuation of the FlexPen on April 1, 2024. The Levemir vial will be discontinued on December 31, 2024.

Levemir will remain preferred on the Preferred Drug List (PDL) so that claims will continue to pay until any remaining stock is depleted

Please refer to the NC Medicaid PDL for alternative preferred options, such as insulin glargine vial/SoloStar^® (authorized biologic for Lantus).

Tips to Prevent Claims Denials and Receive Faster Payment

• Encourage Billing Departments to bookmark the ACNC Claims and Billing Guide (PDF).
• Verify the member’s insurance and eligibility status for any insurance coverages reported via NaviNet.
• Submit claims according to timely filing guidelines of 365 days from the date of service.
• Submit all services on the corrected claim that were on the original claim PLUS the corrected information.
• Avoid handwriting or stamping the words “corrected, resubmitted or voided” on the paper claim — it will cause the claim to be denied.
• Confirm and verify prior authorization by using the Prior Authorization Lookup Tool.
• Ensure accurate coding — code to the highest level of specificity, and use the most current versions of CPT, HCPCS and ICD coding resources.

Electronic Funds Transfer Enrollment Link

ACNC contracts with Change Healthcare and ECHO^® Health, Inc., to administer electronic funds transfer (EFT) payments and electronic remittance advice (ERA). If your practice has not yet registered for EFT, enroll using this direct ACH enrollment link where there are no fees for single-payer agreements. If you have any questions or are experiencing any problems with payments or registration, please contact our Provider Network Account Executive.

Members Earn $25 for Completing a Care Needs Screening

All ACNC members are encouraged to complete a Care Needs Screening (CNS) survey that helps us understand their needs and how to best support them with programs and services. The Care Needs Screening asks questions about health history and habits. If an individual completes the screening within 90 days of enrolling with ACNC, they receive a $25 reward on their CARE Card.

Let’s Work Together: Provider Orientation

Our provider orientation sessions are presented on the 2nd Tuesday of each month from noon to 1 p.m. ET. Our Account Executives host each Let’s Work Together session, sharing tools and information to support provider success as part of our network. Find the registration link on our Provider Training page.

2024 Clinical Leadership Forums

ACNC is pleased to provide opportunities for providers to engage with our team to discuss quality improvement activities and associated challenges, related to quality and population health outcomes. Each lunchtime session includes a Provider Spotlight to highlight best practices, as well as open discussion with participants.

Register for 2024 Forums

Each session is from noon to 1 p.m. ET