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Attention! An update has been made to the content of this web page.

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As previously communicated, significant changes are scheduled to be made in March to the NaviNet web portal. Please review this information to understand how these changes may affect how you do business with AmeriHealth.

NaviNet office conversion

We are converting all NaviNet offices to the new platform on March 20, 2015. Most providers will see a difference in their provider group drop-down menus within many individual transactions on NaviNet.

Some of the more significant changes that providers will see on the new platform include:

• new presentation of provider data within drop-down menu;
• expanded drop-down lists for all office locations associated with a group record;
• elimination of PPO/HMO lines of business designators;
• elimination of customized provider group name descriptions.

As there may be significant impacts to your NaviNet office, we strongly encourage you to review the NaviNet Office Conversion Guide and webinar that will be available soon in the NaviNet Transaction Changes section of our System and Process Changes site.

Allowance Inquiry transaction

A new Allowance Inquiry transaction will be added as an option in the list of transactions, replacing the retired Fee Schedule Inquiry transaction. This new transaction will return fees for professional providers only and will indicate where primary care physician (PCP) capitation is generally applicable. The fees returned via Allowance Inquiry will be associated with migrated members only and will not include results for Traditional or Comprehensive Major Medical members. A detailed user guide will be posted to the NaviNet Transaction Changes section of our System and Process Changes site.

Network Provider Inquiry and Network Facility Inquiry transactions

Two new transactions will be available in March to help you locate physicians or facilities affiliated with a specific AmeriHealth network (e.g., HMO/POS, PPO). Detailed user guides will be posted in the coming weeks on the NaviNet Transaction Changes site.

Referral Submission changes

Beginning March 20, 2015, Procedure Code will be a required field when creating a new referral. In addition, the selection of values under Service Type will be consolidated to include:

• Medical Care (Consult and Treat)
• Consultation
• Dialysis
• Therapy (PT/OT/Hand)

Tiering information enhancements

In order to better serve our Community Advantage and Tier 1 Advantage members, we are introducing NaviNet enhancements on March 20, 2015, that will:

• assist providers in identifying appropriate member cost-sharing (e.g., copayment);
• help providers with the referral and preapproval submission processes.

The following NaviNet transactions will be enhanced with tiering information:

• Eligibility and Benefits Inquiry. A Billing Provider drop-down menu will be added to the search screen. When searching for member eligibility and benefits information, you will need to select the appropriate provider group or facility before entering the member search criteria. The combination of provider and member information entered will assist in identifying the appropriate member cost-sharing. The Eligibility and Benefits Details screen offers several links to benefit provisions. When selecting a benefit link, the member's tier benefit cost-sharing will be highlighted based on the provider group or facility you selected.
  
  Note: Selecting an incorrect provider group or facility on the Eligibility and Benefits Search screen may result in incorrect member cost-sharing information being highlighted.



• Authorization Submission. Where applicable, you will see an additional column in the search results screen when looking for a physician or facility while submitting an Emergency Room Admission Notification or an authorization request for one of the following:
  
  
  • — medical/surgical procedures
  • — chemotherapy/infusion services
  • — home health
  • — home infusion
  • — durable medical equipment
  
  This new column will identify the benefit tier placement associated with that physician or facility. Members with tiered benefit programs pay the lowest cost-sharing when they use providers on the most cost-effective tier.



• Referral Submission. Where applicable, PCPs will see an additional column in the search results screen when looking for a physician or facility while submitting a referral. This new column will identify the benefit tier placement associated with that physician or facility.

Look for a user guide to be posted to the NaviNet Transaction Changes section of our System and Process Changes site for additional details on the upcoming tiering enhancements.

Direct Ship medical injectable drugs

Effective March 20, 2015, the Drug Pre-Authorization transaction will be retired. Therefore, providers will no longer be able to submit Direct Ship requests through NaviNet for medical injectable drugs eligible for coverage under the medical benefit.

Moving forward, providers must download the appropriate drug request form to request direct shipment of a medical injectable drug. Once complete, the form must be faxed, along with a valid prescription, to AmeriHealth at the number listed on the form. These forms also serve as the preapproval/precertification request. If there is not a specific form for the requested drug, providers should use the general Direct Ship Injectables Request Form.

Note: Drugs covered under the pharmacy benefit, including oral, self-injectable, and self-administered drugs, should be submitted through FutureScripts^®, not through the AmeriHealth Direct Ship program.

For more information

We strongly encourage you to review the NaviNet Transaction Changes section of our System and Process Changes site for more information about these changes. We will notify providers through NaviNet Plan Central and the Provider News Center when new user guides and webinars are available. If you have any questions about upcoming changes to NaviNet, please call the eBusiness Hotline at 215-640-7410 for AmeriHealth Pennsylvania and at 609-662-2565 for AmeriHealth New Jersey.

NaviNet is a registered trademark of NaviNet, Inc.