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. There are changes to the application of
medical and claim payment policies that will apply to migrated members on the
new platform.
AmeriHealth policies will be used for adjudication 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. This may result in a different claim
outcome.
To review these policies, which reflect and disclose the different
calculations being used with two claims 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
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
ConnectionTM 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 is available on the AmeriHealth New Jersey website.
For the most up-to-date information about our upcoming transition of
AmeriHealth New Jersey commercial members to the new platform, we encourage you
to visit the System and Process Changes section of the
Provider News Center.