Effective September 1, 2011, the following procedures will apply when requesting precertification through the NaviNet^® web portal or the Provider Automated System through 1-800-275-2583:

• Pain management providers. For precertification requests for pain management procedures (i.e., paravertebral facet joint, transforaminal epidural, and epidural injections), new clinical questions will be added to evaluate medical necessity based on medical policy.
• Durable medical equipment (DME) providers. For precertification requests for CPAP and BiPAP machines, new clinical questions will be added to evaluate medical necessity based on medical policy.
• Home health providers. We will begin reviewing all precertification requests for occupational and physical therapy services in the home beyond the initial 60 days by applying InterQual^® criteria. In addition, we will begin reviewing precertified speech therapy services in the home beyond 60 days based on medical necessity.

We strongly advise reviewing applicable medical policies in advance of requesting precertification so you are prepared to provide the necessary information. Medical policies are available on our website at www.amerihealth.com/medpolicy. Select Accept and Go to Medical Policy Online, and type the name or number of a policy into the Search box.

If you have any questions about these updated procedures, call 1-800-275-2583.

Reminder: Changes to precertification requirements effective September 1*

As previously communicated, we will implement important changes to the list of services and drugs that require precertification effective for dates of service on or after September 1, 2011, for Pennsylvania and Delaware members. Refer to the article in the June edition of Partners in Health Update^SM for a complete list of changes to precertification requirements.

As we proceed through this transition, it is very important for providers to use NaviNet or the most current precertification requirements lists to verify member-specific requirements. The updated lists are available online at www.amerihealth.com/providers/preapproval.

Failure to obtain precertification for any of the services or drugs that require it may result in a reduction in payment or nonpayment for the services not precertified.

Note: These new precertification requirements will apply to commercial members in Pennsylvania and Delaware for dates of service on or after September 1, 2011; Medicare Advantage HMO members will transition for dates of service on or after January 1, 2012.

*Changes will also be made for New Jersey commercial members, but the effective date has yet to be determined. More information will be available in future editions of Partners in Health Update.

NaviNet^? is a registered trademark of NaviNet, Inc.

An AmeriHealth company holds a minority ownership interest in NaviNet, Inc.