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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 and the member may be adversely affected.

Member must be on PCP's LTC panel

Please note the following 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 Provider Partnership Associate or Network Coordinator to establish an LTC provider number.
• The members you provide care to in the LTC setting must be on your LTC panel or the claim may be denied. This could also affect normally capitated services that the member may receive while residing in the LTC/custodial setting.
• Remind your AmeriHealth LTC patients who are not included on your LTC panel that they, or their legal representatives, 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 members and/or their legal representatives of the need to be on their PCP's LTC panel. Please note that LTC locations are not listed in the online Find a Doctor/Hospital tool.

Setting up a PCP LTC panel

To set up an LTC panel, PCPs should contact their Provider Partnership Associate or Network Coordinator.

A PCP's LTC panel uses the same NPI and address as the PCP's office. However, he or she is assigned the Continuing Care Retirement Center taxonomy code of 311Z00000X to distinguish the LTC setting from the office setting.

Following the creation of this new provider record, PCPs will need to register it on the NaviNet^® web portal and set up electronic funds transfer (EFT) – even if they already use these tools at their current practice location.

Billing requirements for members in an LTC facility

Services for members in an LTC facility are to be billed with Place of Service code 32. Taxonomy code 311Z00000X should be used by providers to identify that they are billing for their LTC panel.

PCP LTC panels are reimbursed on a fee-for-service basis.

Failure to submit claims for services performed in the office or LTC facility with the applicable NPI and correct correlating taxonomy code may result in incorrect claims processing.

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. However, members who remain on the PCP office panel will be held to the capitation requirements of their benefits plan. PCPs should submit referrals for LTC panel members in advance of the service being provided. Referrals should be submitted through NaviNet, 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.

If you have any questions about LTC services or setting up a PCP LTC panel, please contact your Provider Partnership Associate or Network Coordinator.

NaviNet is a registered trademark of NaviNet, Inc.

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