Effective January 1, 2015, we are introducing changes related to the application of medical and claim payment policies, as well as clinical relationship logic, for AmeriHealth Medicare Advantage business.

Policy changes

Medical and claim payment policies that currently apply to both commercial and Medicare Advantage business will be separated into two unique policy portfolios: one for Medicare Advantage business and one for commercial business.

The new Medicare Advantage policy portfolio will become effective January 1, 2015; notifications for these policies will be available on the AmeriHealth Medical Policy Portal by October 1, 2014. This policy portfolio will be based on Medicare coverage guidance as well as additional AmeriHealth medical and claim payment policy determinations.

Note: The existing policy portfolio will continue to apply to commercial business.

Clinical relationship logic (procedure code-to-procedure code edits)

Effective January 1, 2015, the following will be applied to claims submitted on the CMS-1500 claim form or through the 837P transaction for Medicare Advantage HMO members:

• Medicare?s National Correct Coding Initiative (NCCI) editing;
• other clinical relationship logic, which is based on procedure code editing standards.

For more information

Additional information about these changes will be provided in future editions of Partners in Health Update^SM.

Stay up to date on policy activity by visiting our Medical Policy Portal. You can also view policy activity using the NaviNet^® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Be sure to check back often, as the site is updated frequently.

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