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In early October, AmeriHealth will transition to a new medical management system for processing authorization requests. To ensure a smooth transition, please read this communication in its entirety as there are changes to several administrative procedures.
NaviNet? enhancements
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 (ER Notification, Medical/Surgical, Chemotherapy Infusion, Home Health, DME, and Home Infusion) 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 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.
New user guides and instructional videos now available
It is important for providers who submit authorization requests to prepare for the upcoming changes to the Authorizations transaction. We encourage you to review the Optimizing Your Browser and Adding Trusted Sites Guide, which can be found in the NaviNet Resources section. Optimizing your browser and adding trusted sites allows data to flow seamlessly between NaviNet and your office, which will improve the performance of the Authorizations transaction.
Additional user guides and tutorials are also available to assist with the submission and inquiry process. If you have questions about the new Authorizations transaction, please contact the eBusiness Hotline at 609-662-2565 for AmeriHealth New Jersey or at 215-640-7410 for AmeriHealth Pennsylvania.
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.
Note: There are no changes to denial procedures; hospitals will continue to be notified verbally and via mail.
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.
Because utilization review and the issuance of determinations will be conducted primarily via fax, we created new fax cover sheets for admission reviews and discharge planning requests. We strongly suggest using these cover sheets to ensure the requests are directed to the appropriate AmeriHealth staff. These fax cover sheets can be found in the Miscellaneous Resources section of AmeriHealth NaviNet Plan Central under Administrative Tools & Resources.
Placement requests
The review of requests for placement in SNFs, inpatient rehabilitation, and long-term acute care facilities will also be handled by a team of nurses on a rotating basis. Hospitals and/or the receiving facilities will request placement by contacting AmeriHealth at 1-800-TO-ADMIT and selecting the Authorizations option, or by fax.
SNF placements may also be initiated through NaviNet. It will be very important to provide updated clinical information at the time of the request to allow for a prompt coverage decision.
Medical codes for services that require precertification
As a reminder, we maintain a Precertification/Preapproval List that outlines the services, items, and specialty drugs that require preapproval/precertification from AmeriHealth. In addition, a supplementary document, Services Requiring Precertification, is available that includes the CPT? and HCPCS codes, where applicable, that correlate with the services, items, and injectable drugs on the Precertification/Preapproval List.
To access Services Requiring Precertification, visit our Medical Policy Portaland select Accept and Go to Medical Policy Online. Then select the Commercial tab from the top of the page. From there, select Services Requiring Precertification from the left-hand menu.
More information
It is 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.
Please review our Transition to a new medical management system: Frequently Asked Questions (FAQ) to help answer any questions you may have about this change. This FAQ can be found in the Frequently Asked Questions section of AmeriHealth NaviNet Plan Central under Administrative Tools & Resources. Note: The FAQ may be updated if more information becomes available.
Additional information regarding this transition will be communicated through Partners in Health UpdateSM and on AmeriHealth NaviNet Plan Central.
CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
NaviNet is a registered trademark of NaviNet, Inc.
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