January 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 January digest:

• Recognizing Highest Earning Independent Practices in Our Network

YOU ARE INVITED

• Join Us for Lunch in Greensboro, Region 2
• FREE Behavioral Health Boot Camp with CME Credits

QUALITY CORNER

• Prenatal and Postpartum Care (PPC) F Codes and Warn Edits

REMINDERS

• Medical Record Data Request for Select Providers
• Issue 3 of Connections Is Now Available
• Value-based Programs Include Medicaid Expansion Members
• Can You Spot the Phish?

Recognizing Highest Earning Independent Practices in Our Network

ACNC’s PerformPlus^® True Care — Behavioral Health Providers Program provides incentives for high-quality and cost-effective care, member service and convenience, and health data submission.

Quality performance is the most important determinant of additional compensation available to providers in this program. Based on quality performance measures consistent with HEDIS or other nationally recognized measures specifically found in the PerformPlus True Care — Behavioral Health Providers Program manual on our Value-Based Programs webpage. Congratulations to the following highest earning independent practices in our network!

• Carolina Family Health Center
• Cornerstone Health
• Jacksonville Children's Multispecialty Clinic
• Our Children's Clinic
• Piedmont HealthCare
• Raeford Pediatrics
• Raleigh Durham Medical Group
• Rural Health Group
• Salisbury Pediatrics
• South Lake Pediatrics

Join Us for Lunch in Greensboro, Region 2

You are invited to meet the Provider Network Management team in Region 2 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, January 30, 2025, from noon to 3 p.m., we will be hosting provider practices at the Greensboro Wellness & Opportunity Center located at 3018 West Gate City Boulevard, Greensboro, North Carolina 27403. We will be discussing the following: claims and billing, compliance, HEDIS, initiatives, resources and more. When you register, please let us know what other topics you would like to discuss.

Register for information session

FREE Behavioral Health Boot Camp with CME Credits

Are more of your patients seeking support for mental health conditions?

If so, join our FREE ECHO Behavioral Health Boot Camp training series. This opportunity is for all pediatricians, primary care family practices, OB/GYNs, local health departments, and behavioral health care providers, along with all clinical staff providing care for our members.

Email projectecho@amerihealthcaritas.com and register for one or more of the following sessions.

Offered 1st and 3rd Wednesdays monthly, February to April 2025, from noon until 1 p.m.

Participants who complete components of this series can earn continuing medical education (CME) credits for physicians, Approved Continuing Education (ACE) credits for social workers, and continuing education units (CEU) for nurses through the University of New Mexico (UNM).

Prenatal and Postpartum Care (PPC) F Codes and Warn Edits

Effective September 3, 2024, ACNC began placing a warn edit on delivery claims that were submitted without an 0500F either on the delivery claim or within 270 days prior to the delivery date. This edit was put into place to alert that 0500F has not been billed, and at this time the delivery claim will still be paid if all other billing guidelines are followed. Beginning July 1, 2025, in accordance with NC DHHS policy 1E-5, if the 0500F code has not been submitted with the delivery claim or within 270 days prior to the delivery date, the claim will be denied.

NC Medicaid’s Obstetrical Services Clinical Coverage Policy No: 1E-5 (PDF), updated June 15, 2024, requires the use of two new CPT billing codes for prenatal and postpartum care. These codes will assist in capturing information about the timeliness of prenatal and postpartum care provided to NC Medicaid members. The two F codes are 0500F for initial prenatal visits and 0503F for postpartum care visits. Both codes are defined in the NCQA HEDIS value sets and are meant to support more accurate and complete data collection around prenatal and postpartum care delivery in North Carolina.

After July 1, 2025, delivery claims (including global or package billing codes) submitted to NC Medicaid Direct and managed care plans will be denied without a code for 0500F (initial prenatal care visit) in the patient’s history, as defined by the revised NC Medicaid Obstetrical Services Clinical Coverage Policy.

NC DHHS has published a PPC F Codes Fact Sheet and Frequently Asked Questions document that aim to give providers and practices more information about these new F codes, why they are important, and how they should be used.

• PPC F Codes Fact Sheet (PDF) — July 2024
• PPC F Codes Frequently Asked Questions Document (PDF) — July 2024

If you have any questions regarding this program, please contact your Provider Network Account Executive.

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.

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:

1. Metric including the Medicaid expansion population.
2. 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.

Can You Spot the Phish?

More than 3.4 billion phishing emails are sent out each day worldwide. But one factor can make life much harder for scammers: You. As the first line of defense, it is important that you are able to recognize and report a suspected phishing email.

What is phishing?

Phishing scams are emails that look real, but they are designed to steal important information. A phishing email with malicious software can allow cybercriminals to take control of your computer and put protected health information (PHI) and personally identifiable information (PII), as well as your organization’s confidential and proprietary information, at risk.

Beware of ransomware

In addition to stealing information, phishing scams can lead to ransomware attacks. Ransomware is a form of malware designed to encrypt files on a device, rendering them unusable until a ransom is paid.
It may be a phishing email if it:

• Promises something of value (e.g., “Win a free gift card!”)
• Asks for money or donations
• Comes from a sender or company you don’t recognize
• Links to a site that is different than the company the sender claims to be from
• Asks you for personal information, such as your username and password/passphrase
• Includes misspelled words in the site’s URL address or subject line
• Has a sense of urgency for you to act now

What you should do

If you receive a suspicious email:

• Do not click any links in the email.
• Do not provide your username and password; you should never share your username or password, even if you recognize the source. Phishing scams frequently mimic well-known companies, such as banks or retailers like Target or Amazon.
• Do not reply/respond to the email or forward it to anyone else within your organization.
• Familiarize yourself with your organization’s process for reporting suspicious emails. If you suspect an email is a phishing attempt, report it immediately.
• Your organization's information security department may have additional information and guidance on how to protect yourself from phishing scams.