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As previously communicated, the migration of AmeriHealth New Jersey commercial members to the new operating platform begins on September 1, 2015. The migration will occur in two waves: some groups will transition on September 1, 2015, and the remaining AmeriHealth New Jersey commercial members will transition on October 1, 2015. We expect all AmeriHealth members (i.e., Pennsylvania, New Jersey, commercial, and Medicare Advantage) to be on the new platform as of October 1, 2015.
During the migration, we will be working with you in a dual claims-processing environment until all AmeriHealth New Jersey commercial members are migrated to the new platform on October 1. The date of service will determine the platform on which these claims will be processed.
This article summarizes the important changes that we have communicated this year that will affect the way you do business both during and following the migration.
Members issued new ID cards
Members will be issued a new ID card upon migration. ID cards for migrated members differ from non-migratedmember ID cards in the following ways:
- AmeriHealth will assign a new 12-digit member ID number, called a "unique member ID" (UMI).
- The subscriber and all members covered under the subscriber's policy will share the same ID number. Eachmember ID card will include the member's name and subscriber UMI.
- AmeriHealth New Jersey commercial member ID cards will now indicate in which network the member is enrolled.The AmeriHealth New Jersey network indicator will be located on the top right section of the card, includingdesignations such as Local Value and Regional Preferred. If the AmeriHealth New Jersey commercial member isenrolled in the National Access network through Private Healthcare Systems, Inc. (PHCS), the logo will also beincluded on the bottom right of the ID card.
It is imperative that provider offices do the following:
- obtain a copy of the member's ID card at every visit to ensure that you submit the most up-to-dateinformation to AmeriHealth;
- verify eligibility and benefits using the NaviNet® web portal prior to rendering service.
Below are several sample ID cards for migrated members:
Claim submission requirements
The use of a valid National Provider Identifier (NPI) and taxonomy codes are required on all migrated member claims to ensure proper claims processing.
Valid NPI
It is critical that you submit all claims with a valid NPI. The new claims processing system reviews each claim for this data. Providers should work with their clearinghouse/trading partner to ensure accurate claims submission. The most common reasons that an NPI would be considered invalid are:
- The NPI is terminated.
- The NPI is entered incorrectly.
- The number is invalid.
Using an invalid NPI could delay processing and payment. For additional information about NPI regulations, implementations, reports, and resources, go to our
website.
Taxonomy codes
If your group NPI is associated with more than one AmeriHealth specialty, you must include the appropriate provider taxonomy code in addition to the NPI on all claims. This allows the accurate application of the provider's contractual business arrangements with AmeriHealth. Failure to submit claims with the applicable NPI and correct correlating taxonomy code may result in incorrect claims processing and/or payment delays.
Refer to the article, Guidelines for billing with taxonomy codes and use of NPI on claims, in the August 2015 edition of Partners in Health UpdateSM for an illustration of how to correctly submit your taxonomy code.
Provider Automated System
Once an AmeriHealth member is migrated to the new platform, you can no longer use the Provider Automated System for that member. Therefore, as of October 1, 2015, the Provider Automated System will no longer be available for any AmeriHealth members, as they will have all been migrated to the new platform. You must use NaviNet to retrieve information such as eligibility and benefits or claims status.
Provider payment
For claims processed on the new platform, payments will be made weekly, as opposed to daily, for providers that bill an 837/UB claim type.
In addition, providers no longer receive a Statement of Remittance (SOR) for migrated members. Professional providers receive what is called the Provider Explanation of Benefits (EOB), and facility providers receive what is called the Provider Remittance. The Provider EOB and Provider Remittance have a new look and format from the former SOR. On the new format for facility claims, services are combined and displayed on one line.
Detailed guides for the Provider EOB and Provider Remittance are available in the Claims Submission and Payments section of the System and Process Changes site. Terms are explained to assist you in interpreting your payment statements.
NaviNet functionality changes for migrated members
The following functionality on NaviNet is applicable only to migrated members; therefore, it will apply to AmeriHealth New Jersey commercial members upon migration:
- EOB and Remittance. Once a member has been migrated to the new platform, participating providers can use the EOB and Remittance transaction to get claim payment information for finalized claims processed on the new platform. Through this transaction, providers can download and/or print their Provider EOB or Provider Remittance for migrated members. Providers can also search for statements in two-week increments.
- Claims Investigation. For finalized migrated member claims, providers can utilize the Claim Investigation Inquiry transaction. This transaction allows providers to submit an adjustment for an individual claim and will permit limited claim editing (excluding the ability to submit late charges).
- Cap Rosters. If you are enabled for electronic funds transfer (EFT), you will no longer receive paper rosters/reports for AmeriHealth New Jersey commercial members once they are migrated to the new platform. Refer to the article, Interpreting your PCP payments via EFT, in this edition of Partners in Health Update for more information.
For more detailed information about using these transactions for migrated member claims, please refer to the article,
NaviNet functionality will apply to New Jersey commercial members upon migration to the new platform, published in the June 2015 edition of
Partners in Health Update.
Claims processing requirements
Some differences in claims processing and outcomes will apply to AmeriHealth New Jersey commercial members upon migration:
- Multiple Surgical Reduction Guidelines. For professional providers, the calculation method used in applying Multiple Surgical Reduction Guidelines for migrated members is based on the procedure reported "Allowed Amount" and not the derived "Surgical Ranking", which was used on the old platform. This may result in a different claim outcome.
To review the policies that disclose the different calculations being used for the two platforms, refer to our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you'd like to view. Then type the policy name or number in the Search field:
-- Commercial: #11.00.10s: Multiple Surgical Reduction Guidelines
-- Medicare Advantage: #MA11.032b: Multiple Surgical Reduction Guidelines
- Clinical Relationship Logic. Clinical Relationship Logic, or Code-to-Code Edits (e.g., incidental, integral, component, mutually exclusive), applied to services reported on a CMS-1500 claim form or electronic equivalent may differ depending on whether the claim is processed on the old or new platform. Clinical Relationship Logic, which is based on national standards, is used for migrated claims and is available on the AmeriHealth New Jersey website. The McKesson ClaimCheck® product will not be used on the new platform.
In a recent analysis of rejection rates of migrated claims, we found some common reasons why claims are rejecting on the new platform. For detailed information about reasons for claim rejections, please refer to the article,
Upcoming changes to claims processing requirements and enforcing these changes for AmeriHealth New Jersey members, published in the August 2015 edition of
Partners in Health Update.
Resources
We will continue to work closely with you and our entire provider network as we complete our platform transition. For more information related to this transition, please visit our dedicated System and Process Changes site. On this site you will find a communication archive as well as frequently asked questions. If you still have questions after reviewing these resources, email us.
NaviNet is a registered trademark of NaviNet, Inc.
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