This is a reminder of the requirements for primary care physicians (PCP)
when rendering services to members in long-term care (LTC) facilities. It is
important to adhere to these requirements when providing such services or your
claims may be denied. This information is documented in the Provider Manual
for Participating Professional Providers and was previously published in
Partners in Health UpdateSM.
Member must be on PCP?s LTC panel
Please note the following two requirements related to PCPs and their LTC
panel:
- PCPs who provide services to members in an LTC/custodial setting
must have a separate LTC provider number established in our
system. This separate provider number must be used when submitting claims for
services rendered to members residing in an LTC facility (custodial members).
If you do not have a separate LTC provider number and you are seeing
AmeriHealth members residing in an LTC/custodial setting, please contact your
Network Coordinator or Provider Partnership Associate to establish the LTC
provider number.
- The members you provide care to in the LTC setting must be on your
LTC panel or the claim will be denied. Please remind your AmeriHealth
LTC patients who are not included on your panel that they, or their legal
representative, need to contact Customer Service to select your LTC
location. You may also want to consult with the administrative staff
of the LTC facility to
assist with educating the members and/or their legal representative of the need
to be on the PCP?s LTC panel.
Note: Members who are on your office panel but now reside in an LTC
facility must contact Customer Service in order to be moved to your LTC
panel.
Referral requirements for members in
LTC
PCPs with an LTC panel must issue a referral to an in-network provider for
any professional service or consultation for an LTC-panel member in LTC. This
requirement includes:
- podiatry, physical therapy, and radiology services
- consultation or follow-up with a specialist
- ancillary services
Note: LTC-panel members do not have capitation requirements for
laboratory, physical therapy, or radiology services. Also, the services listed
above do not require precertification.
PCPs should submit referrals for LTC-panel members in advance of the service
being provided. Referrals can be submitted by using the NaviNet®
web portal, and they should be submitted in a timely manner to allow for
appropriate claims processing. Claims will not be authorized for payment
without a referral on file. In addition, consultants and ancillary providers
are encouraged to provide the referral information with the claim to assist in
processing.
Billing requirements for members in an LTC
facility
Services for members in custodial care are to be billed with Place of
Service code 32.
If you have any questions about LTC services, please contact your Network
Coordinator or Provider Partnership Associate.
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