As you know, all AmeriHealth New Jersey Medicare Advantage members were migrated to the new operating platform on January 1, 2015. AmeriHealth New Jersey commercial members will be migrated to the new platform between September 1, 2015, and October 1, 2015. On the new platform there are changes to the enforcement of medical and claim payment policies that will apply to migrated members.

AmeriHealth policies will be enforced on both the current and new claims processing platforms; however, some differences in claims processing and outcomes between the two systems may occur for AmeriHealth New Jersey members as described below.

Multiple Surgical Reduction Guidelines

For professional providers, the calculation method used in applying Multiple Surgical Reduction Guidelines for members on the new platform will be based on the procedure reported "Allowed Amount" and not the derived "Surgical Ranking," which is used on the old platform.

To review these policies, which reflect and disclose the different calculations being used with two claims platforms, refer to the policies available on 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 Notification you'd like to view. Then type the policy name or number in the Search field:

• Commercial: #11.00.10r: Multiple Surgical Reduction Guidelines
• Medicare Advantage: #MA11.032a: 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 for AmeriHealth New Jersey member claims depending on whether the claim is processing on the old or new platform. The McKesson ClaimCheck^® product will not be used on the new platform.

Clinical Relationship Logic, which is based on national standards, will be applied to claims for AmeriHealth New Jersey members processed on the new platform. Clinical Relationship Logic applied to professional claims will be disclosed according to the following:

• On the old platform (i.e., for AmeriHealth New Jersey commercial members who have not yet been migrated). Clinical Relationship Logic applied to professional claims for members processed on the old platform will continue to be disclosed through the current Clear Claim Connection™ tool, which is available on the NaviNet^® web portal within the Claim Inquiry and Maintenance transaction or on the AmeriHealth New Jersey website.
• On the new platform (i.e., for migrated members). Clinical Relationship Logic applied to professional claims for AmeriHealth New Jersey members processed on the new platform will be made available on the AmeriHealth New Jersey website.

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