February 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 February digest:

• ACNC Eases Administrative Burden and Improves Member Access With Reductions in Prior Authorization Requirements

QUALITY CORNER

• Childhood Immunization (CIS) Combo 10 HEDIS Measure
• Medical Record Data Request for Select Providers

MEMBER SPOTLIGHT

• Let Us Know Program Referrals

CLAIMS AND BILLING

• Claims and Billing Manual Updated
• Restoration of Optum/Change Healthcare Connectivity
• Encourage Your Patients to Quit Tobacco Products

REMINDERS

• Tobacco Cessation News
• Join Us for Lunch in Fayetteville, Region 5

ACNC Eases Administrative Burden and Improves Member Access With Reductions in Prior Authorization Requirements

Member access to timely, high-quality physical and behavioral health care is the highest priority for AmeriHealth Caritas North Carolina (ACNC). We recognize that valuable treatment time can be lost for our members when providers are saddled with overly restrictive processes.

As part of our ongoing commitment to members and providers, ACNC has eliminated prior authorization requirements for more than 1,900 physical and behavioral health procedure codes since 2023.

The latest updates took effect January 1, 2025:

• Prior authorization and notification requirements have been removed for more than 240 physical health codes, including a select number of durable medical equipment, physical and occupational therapies, orthotics and prosthetics, and surgery codes.
• To further our goal of mental health parity, notifications are no longer required for behavioral health codes and prior authorization requirements were eliminated for more than a dozen services including, but not limited to, facility-based crisis treatment, mobile crisis management, and outpatient treatments

For the most up-to-date information on prior authorizations for all services, use our Prior Authorization Lookup tool. If you have questions about these changes, or further suggestions, please reach out to your dedicated ACNC Account Executive.

Childhood Immunization (CIS) Combo 10 HEDIS Measure

The Childhood Immunization (CIS) Combo 10 HEDIS measure is the percentage of children who have received the required vaccinations by their second birthday.

The required vaccines in the Combo 10 series are:

• Four diphtheria, tetanus, and acellular pertussis (DTaP)
• Three polio (IPV)
• One measles, mumps, and rubella (MMR)
• Three haemophilus influenzae type B (HiB)
• Three hepatitis B (HepB)
• One chicken pox (VZV)
• Four pneumococcal conjugate (PCV)
• One hepatitis A (HepA)
• Two or three rotavirus (RV)
• Two influenza (Flu)¹

Rotavirus vaccination

One of the two available rotavirus vaccines should be given.

• RotaTeq (RV5) should be given as three doses. One dose is given when the child is 2 months old, another when the child is 4 months old, and the third when the child is 6 months old.
• Rotarix (RV1) should be given as two doses, one when the child is 2 months old and the other when the child is 4 months old.²

“Can RotaTeq and Rotarix vaccines be used interchangeably?”³

• The Advisory Committee on Immunization Practices (ACIP) “recommends that the rotavirus vaccine series be completed with the same product whenever possible. However, vaccination should not be deferred because the product used for a previous dose is not available or is unknown. In these situations, the provider should continue or complete the series with the product available. If any dose in the series was RotaTeq, or the vaccine product is unknown for any dose in the series, a total of 3 doses of rotavirus vaccine should be administered. The minimum interval between doses of rotavirus vaccine is 4 weeks. All doses should be administered by age 8 months and 0 days.”³
• To meet CIS Combo 10, the two-dose series or three-dose series of the rotavirus vaccine must be documented as fully completed.

Best practices to meet the CIS Combo 10 measure include:

• “Offer walk-in or immunization-only visits to all patients.”⁴
• Enter all administered immunizations into the North Carolina Immunization Registry (NCIR). “Update all historical immunization information into the NCIR as soon as the information is available.”⁴
• When a child’s siblings are at the appointment, check the vaccination records of all children present. Schedule them for an immunization-only visit.
• Prior to an appointment, call or send a reminder to the child’s guardians to bring updated immunization records.
• When a child misses an appointment, contact their guardian. Reschedule the appointment as soon as possible.
• Ensure that all immunization appointments are prior to the 2nd birthday.

Please contact your Provider Network Management Account Executive with any questions.

For providers that would be interested in partnering with ACNC on vaccine events please contact ACNC quality management by email at ACNCQualityManagement@amerihealthcaritas.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. A frequently asked questions (FAQ) document can be found in the NaviNet Provider Portal under Resources.

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.

Let Us Know Program Referrals

Do you find it hard to help some patients engage with their health? If so, Let Us Know and we’ll give it a try. The Let Us Know program alerts us that one of our members might need additional support. We can help with things like missed appointments, behavioral health referrals, medication noncompliance, tobacco cessation, food and housing.

Review our new Let Us Know webpage for more information or connect directly to our team, by using the Member Intervention Request Form (PDF).

Claims and Billing Manual Updated

Our Claims and Billing Manual has been updated to version 11 and posted to our website. This manual will help you avoid delays in the processing of your claims. See the Claims and Billing Guide Revision Log on page 107 for a complete list of updates. If you have questions, contact your dedicated Provider Network Management Account Executive.

Restoration of Optum/Change Healthcare Connectivity

ACNC has restored connectivity with Optum/Change Healthcare. Please see the Claims and Billing webpage for the most up-to-date options for claims submission. Manual (or direct) entry and electronic submission (including 275 attachments) are both available. If you have questions, please contact your Provider Network Management Account Executive or Provider Services at 1‑888-738-0004.

Encourage Your Patients to Quit Tobacco Products

Not all providers are aware that counseling patients who smoke cigarettes, tobacco or vape products to quit is a billable service under NC Medicaid. If you, or a provider in your practice, offers smoking or tobacco use cessation strategies and medical assistance to a Medicaid beneficiary and includes documentation in the medical record, please use the following CPT codes on claims to ACNC.

Providers may bill the above codes only when counseling is provided directly to the beneficiary. These CPT codes are only appropriate for use when the patient is receiving the counseling for tobacco use.

Note: Modifiers are required on claim details when entering CPT 99406-99407.

For Medicaid beneficiaries 11 years through 20 years of age receiving counseling for smoking/tobacco cessation as part of a Health Check Wellness Visit, sick child or E/M visit, the code should be accompanied by modifier 25 to indicate that a separate and identifiable service was delivered in addition to the visit. When the service is provided as part of a Health Check Early Periodic Screening visit, the EP modifier must be appended.

Providers should always include documentation in the member’s medical record noting the intervention, patient response and current status, follow-up plan and referrals.

CPT codes, descriptions and two-digit numeric modifiers are copyright 2022 American Medical Association. All rights reserved.

Tobacco Cessation News

Wherever you or your agency is on the Road Map to Tobacco-free, you are invited to join the 2025 Change for Life Coalition meetings. This is a monthly peer-to-peer coalition of providers sharing resources, lessons learned and tips for implementing a tobacco-free culture of care. Register for the 2025 meeting series that meets the fourth Thursday of the month, from 9a-10:15am.

Register for Change for Life Coalition

To subscribe to the weekly Tobacco Ripple Effect Newsletter, contact Ashley Curtice at ashley.curtice@dhhs.nc.gov.

Reprinted with permission from Ashley Curtice from North Carolina Department of Health and Human Services.

Join Us for Lunch in Fayetteville, Region 5

You are invited to meet the Provider Network Management team in Region 5 for lunch and an information session. 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, February 27, 2025, from noon to 3 p.m., we will be hosting provider practices at the Fayetteville Wellness & Opportunity Center, located at 4101 Raeford Road, North Carolina 28304. We will be discussing the following: claims and billing, prior authorizations, compliance, HEDIS, initiatives, resources and more. Register by Tuesday February 25, 2025, and let us know what other topics you would like to discuss.

Register for information session