March Provider Digest

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

• Prior Authorization Reminder

QUALITY CORNER

• Glycemic Status Assessment for Patients with Diabetes (GSD) HEDIS Measure
• Medical Record Data Request for Select Providers
• Regional Baby Showers

CLAIMS AND BILLING

• Navigating Electronic Visit Verification, Crosswalks and More
• Use the Correct Payer ID When Filing Claims

PHARMACY

• ACNC Upcoming Pharmacy Changes

MEMBER BENEFIT SPOTLIGHT

• No-cost Non-emergency Transportation for ACNC Members

TRAININGS AND FORUMS

• Preparing for a Tobacco-Free Campus
• Let’s Work Together: Provider Orientation
• Electronic Funds Transfer Enrollment Link
• 2024 Clinical Leadership Forums

Prior Authorization Reminder

Durable medical equipment (DME) providers and those requesting authorizations for medically necessary units or specific procedures should review the North Carolina Department of Health and Human Services (NCDHHS) Program Specific Clinical Coverage Policies before submitting a request. If your authorization request exceeds the established NCDHHS Program Specific Clinical Coverage Policy limits, providers should indicate “unit exception request” anywhere in the Service Information section of the prior authorization request form (PDF).

Glycemic Status Assessment for Patients with Diabetes (GSD) HEDIS Measure

The GSD measure (formerly known as Hemoglobin A1c Control for Patients with Diabetes, or HBD) is the percentage of members 18 – 75 years of age with diabetes (types 1 and 2) whose most recent glycemic status (HbA1c or glucose management indicator [GMI]) was at the following levels during the measurement year:

• Glycemic status less than 8%
• Glycemic status greater than 9%

Best GSD practices:

• Check for missing HbA1c results at each diabetic member’s visit, and order appropriate labs prior to the patient’s appointments or use point-of-care testing.
• Test the patient’s HbA1c every 3 – 6 months.
• Consider diabetic self-management education and support classes (DSMES) for non-adherent patients.
• Assess for any social determinants of health that may be a barrier for adherence to provider guidance.
• Send out follow-up reminders to each diabetic member by text, mail or phone, and reach out to non-adherent diabetic members to schedule their next visit.
• Educate patients on the importance of HbA1c testing and healthy lifestyle options.
  • Use CPT Category II coding for claims submission. Please see the guidance below: 
  • Less than 7%: 3044F
  • Greater than or equal to 7% and less than 8%: 3051F
  • Greater than or equal to 8% and less than/equal to 9%: 3052F
  • Greater than 9%: 3046F
• Include the date of the HbA1c test and the actual result; don’t use ranges and thresholds.

Include the date of the HbA1c test and the actual result; don’t use ranges and thresholds. AmeriHealth Caritas North Carolina offers a $10 incentive for members every 6 months for maintaining HbA1c results of less than 9%.

Please contact your Provider Network Management Account Executive or Practice Transformation Associate with any questions. 

For providers who would be interested in partnering with ACNC on HbA1c events, please contact ACNC quality management by email at acncqualitymanagement@amerihealthcaritas.com.

Medical Record Data Request for Select Providers

The annual Healthcare Effectiveness Data and Information Set (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 ComplexCare Solutions, formerly known as Inovalon, to manage the medical record retrieval for the annual medical record review process. ComplexCare Solutions 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 ComplexCare Solutions 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 Melissa Lawson, Lead Data Reviewer, at 215-863-6318. We greatly appreciate your cooperation and timely assistance with this medical record request.

Regional Baby Showers

ACNC continues work to improve maternal health outcomes, especially among people of color, by hosting regional community baby showers at our Wellness & Opportunity Centers and partner locations across the state. Our goal is to educate, empower and support women who have recently delivered a baby or who are pregnant, as well as their families.

Our baby showers offer us a chance to celebrate the arrival of new babies and encourage moms to get the prenatal and postpartum care and support they need. Please share these opportunities with your patients and have them register via the event calendar links on the Wellness & Opportunity Centers webpage. ACNC members can get no-cost transportation to any of our sponsored events through our transportation provider, ModivCare.

If your practice is interested in participating in a baby shower event, please contact our ACNC Quality Management team.

ACNC Upcoming Pharmacy Changes

The NC Medicaid Preferred Drug List update will occur April 1, 2024. For assistance with pharmacy prior authorizations or pharmacy claim questions, contact PerformRx^SM Provider Services at 1-866-885-1406. 

No-cost Non-emergency Transportation for ACNC Members

Providers are encouraged to review our non-emergency medical transportation (NEMT) (PDF) self-paced presentation on our website. ACNC provides its Medicaid managed care members with NEMT to and from medical appointments at no cost to the member. The benefit can include transportation to medical appointments using:

• Public transit — bus or rail
• Sedan, van or taxi
• Wheelchair-accessible van vehicle
• Non-emergency ambulance
• Non-emergency commercial air travel
• Mileage reimbursement for members who drive themselves

Ride requests should be made up to two days in advance, directly through Modivcare, Monday through Saturday. One-way trips cannot exceed 75 miles. Members who have transportation or drive themselves to appointments can receive mileage reimbursement at the current IRS rate, which is 65.5 cents per mile. Those seeking reimbursement must complete a paper form or a form in the Modivcare app, available for smartphones. The Modivcare app makes it easy to book a ride, or record mileage and apply for reimbursement. The app can be downloaded from Google Play or the Apple App Store

As an added value benefit, ACNC offers transportation support for members to attend programs at any of our Wellness & Opportunity Centers.

Preparing for a Tobacco-Free Campus

Providers are invited to attend a discussion regarding preparing for a tobacco-free campus during the Tobacco-Free Recovery NC Meeting being held on March 28, from 9:00 to 10:15 a.m. Brian Coon MA, LCAS, CCS, MAC, Chief Clinical Officer at Pavillon, will discuss: Why, how, and when to train staff for a tobacco-free campus while offering treatment. (Reprinted with permission from Stephanie Gans from NCDHHS.)

Register for Tobacco-Free Recovery NC Meeting

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.

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.

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

Check back often on our Training webpage for the latest educational, forum and self-paced training opportunities. We continue to offer ways for our providers to engage with Quality measures, resources and our teams.