During the third quarter of 2017, AmeriHealth will transition to a new medical management system for processing requests for Authorization. Please read this communication in its entirety as it includes a request for action. This transition will require changes to several administrative procedures, as noted below.

NaviNet^®

The Authorizations transaction on the NaviNet web portal will be upgraded. Enhancements will include the following:

• Streamlined workflow. The new transaction will streamline the various authorization submission types into one workflow.
• Authorization status. The new transaction will allow providers to search for a list of their submitted authorization requests based on a user-defined date range. Providers will no longer be required to limit their search to a specific member. This new feature will be especially helpful for providers submitting a significant number of prior authorization requests. If you do not have a NaviNet username and password and you anticipate a need to utilize this function, please see your designated NaviNet Security Officer to obtain a logon to the web portal. Note: Denial notices will continue to be sent via mail.
• SNF and non-emergency ambulance transportation. Requests for coverage for placement in a skilled nursing facility (SNF) and for non-emergency ambulance transportation will be accepted through the new Authorizations transaction.

Look for more detailed information in the coming months. New user guides will be made available prior to the release of the new transaction to help your office understand these enhancements.

Emergency (unscheduled) admissions

Cases that initially present to the emergency department, but are subsequently determined by the treating physician to require hospital confinement will require further review when payment is being requested for inpatient admission. Once notification of the admission is submitted via NaviNet, clinical information allowing for utilization review must be provided within 72 hours. In the event such information is not submitted within 72 hours, the case will be reviewed and a utilization review determination will be based on whatever information was included in the initial notification, which will most likely be insufficient to satisfy the applicable clinical criteria.

New administrative procedures for hospitals

AmeriHealth will no longer identify a specific utilization review nurse to service a given network hospital. Instead, cases will be handled by a team of nurses on a rotating basis.

Utilization review and the issuance of determinations will be conducted primarily via fax. Therefore, it is imperative that we have your most current fax information on file. You can update your fax number as outlined in the Administrative section of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers. New fax numbers and fax cover sheets will be provided as we get closer to the transition.

Stay informed

It will be important for providers who submit authorization requests to stay current with ongoing announcements related to this system transition to ensure your organization is prepared when the changes are implemented.

Additional information regarding this transition will be communicated through Partners in Health Update^SM and on NaviNet Plan Central. If you have any questions, please call our eBusiness Hotline at 609-662-2565 for AmeriHealth New Jersey or at 215-640-7410 for AmeriHealth Pennsylvania.

NaviNet is a registered trademark of NaviNet, Inc.