This month, you will see additional changes to the NaviNet web portal as we continue to transition our claims processing for AmeriHealth Pennsylvania members to a new operating platform. This article describes new transactions that will be introduced starting December 13, 2013.

Reminder: When conducting transactions from AmeriHealth NaviNet Plan Central, search results will include information only for members covered under AmeriHealth plans. Please ensure you have access to all applicable health plans you do business with.

EOB and Remittance Inquiry

Starting December 13, 2013, the new EOB and Remittance Inquiry transaction will be made available to all participating providers who are NaviNet-enabled (i.e., no enrollment for the transaction is necessary). This transaction will provide claims payment information for finalized claims processed after December 13, 2013, on the new platform.

To access the transaction, select ePayment from the Plan Transactions menu, and then EOB and Remittance Inquiry. Your designated Security Officer will have immediate access to the transaction once it?s available; he or she will manage access for applicable staff through the User Management transaction.

Through this transaction, providers will be able to download and/or print their Provider Explanation of Benefits (EOB) (for professional providers) or Provider Remittance (for facility providers). Providers will also be able to search for statements in two-week increments. In addition, beginning December 13, 2013, providers will start building a history of stored statements ? ultimately having four months of historical remittance data available. For this reason, it will be important to download and save reports on a regular basis.

The statements will include A/R detail, when appropriate. A single Provider EOB or Provider Remittance may contain multiple PDF documents. The various payment types include:

• spending account payment
• remittance payment
• facility remittance

Guides to help you interpret your Provider EOB or Provider Remittance will be available soon on the Upcoming System and Process Changes section of the Provider News Center. Look for more information about these guides in future editions of Partners in Health Update.

Providers currently enrolled for the Online Statement of Remittance (SOR) will continue to have access to remittance data for claims processed on the current platform (i.e., for AmeriHealth New Jersey and Delaware members and AmeriHealth Pennsylvania members who have not yet been migrated to the new platform). When the claim service date range spans migration (i.e., dates of service prior to and post member migration), you can expect the following:

• Facility claims. If the date of admission occurred prior to the member?s migration, the claim will be processed on the current platform, and resulting remittance data will be available through the Online SOR transaction. If the date of admission occurred after the member was migrated, the claim will be processed on the new platform, and the resulting remittance data will be available through the new EOB and Remittance Inquiry transaction.
• Professional claims:
• If the date of service is before the member is migrated to the new platform: The claim will be processed on the current platform, and the resulting remittance data will be available through the Online SOR transaction.
• If the date of service is after the member is migrated to the new platform: The claim will be processed on the new platform, and the resulting remittance data will be available through the new EOB and Remittance Inquiry transaction.
• If dates of service include dates both pre- and post-member migration: The claim will be split. For dates of service prior to member migration, the specified service lines will be processed on the current platform, and the resulting remittance data will be available through the Online SOR transaction. For dates of service after member migration, the specified service lines will be processed on the new platform, and the resulting remittance data will be available through the new EOB and Remittance Inquiry transaction.

Cap Rosters

Updated Cap Roster transactions will be available starting December 13, 2013. Please note that these transactions will only include information for AmeriHealth members.

For the transactions detailed in this section, you will need to select the month from the search screen. You will also have the option to search by provider group or tax ID number. The report itself will include summary and detail sections. Within the detail section, you will be able to sort the columns as needed. You will also have a new search text field, which will allow you to customize a filter.

Refer to the following for information specific to each transaction:

• PCP Capitation Rosters. To access primary care physician (PCP) reports, continue to select ePayment from the Plan Transactions menu, and then PCP Cap Rosters. Up to 13 months of historical data will be available.
• Specialist Capitation Rosters. Capitation rosters will be available for our specialist radiology and physical therapy providers. Our capitated facilities and capitated specialists will have access to these rosters. Your designated Security Officer will control user access. To access capitation rosters, select ePayment from the Plan Transactions menu, and then Specialist Cap Rosters. The January 2014 report will be the first one available to you. With each new month, you will begin to build a history of stored reports. Ultimately, up to 13 months of historical data will be available.

Note: If you are enabled for electronic funds transfer (EFT), you will no longer receive paper rosters/reports for migrated members. All EFT-enabled providers must access capitation rosters using NaviNet.

Claims Investigation (Claims INFO)

The Plan Transactions menu will no longer include the Claims INFO Adjustment Submission transaction as a stand-alone option. Claims adjustment requests will be submitted through the new Claims Investigation transaction. Access Claims Investigation by using the link provided on the Claim Status Inquiry Summary or Detail Screens. Only finalized claims (i.e., paid or denied) will display the link for Claims Investigation.

Providers who access a claim through the Claim Status Inquiry transaction can expect the following:

• For finalized claims processed on the current platform (i.e., for non-migrated members): Providers will be offered the new Claims Investigation link. Providers can submit an adjustment for an individual claim and will be permitted to edit the claim (including the ability to submit late charges).
• For finalized claims on the new platform (i.e., for migrated AmeriHealth Pennsylvania members): Providers will be offered the new Claims Investigation link. The transaction will allow providers to submit an adjustment for an individual claim and will permit limited claim editing (excluding the ability to submit late charges). When initiating an adjustment, you will be requested to select one of the following Adjustment Types:
• Claim Denied No Auth/Referral
• Claim Paid Low Level in Error
• Claim Pending over 45 Days
• COB Related
• Discrepancy on How Claim Processed
• Follow Up to Previous Investigation
• Medicare Related
• Membership/Enrollment Denial
• NIA Retrospective Review
• Refund Request/Check Reissue

After selecting the Adjustment Type, proceed to the provided text box to indicate the details of your request. Individual claim service lines will no longer be provided, and your contact information and telephone number continue to be required fields. You will receive a response message after submitting your adjustment; however, a unique adjustment ID will not be assigned. If you need to add late charges or make other significant changes to the original claim, you will need to submit a corrected claim through your normal claim processing channels.

The Plan Transactions menu will also no longer include the Claims INFO Adjustment Inquiry transaction as a stand-alone option. To check the status of a previously submitted adjustment request, use the new Claims Investigation Inquiry transaction. After selecting your provider group, complete the Request Date To and Request Date From fields. Note: The Request Date To will default to today?s date, and the Request Date From will default to 30 days prior to the current date. You can modify these dates, but the date span cannot exceed one month. Up to 18 months of historical data will be available to you. Other optional fields are also available for the Adjustment ID or Investigation Status (open/closed).

Authorizations

Effective January 1, 2014, all managed care products will follow the same precertification requirement list. For more structured plans (i.e., HMO, POS), this equates to a reduction in authorizations and an easing of administrative effort. HMO members will still require a referral to see a specialist, but not for the procedure itself, and they must see a provider participating in HMO network for coverage. For PPO plans, this means a change in the type of procedures that will require authorization and a slight increase in volume.

These changes will be reflected in four key authorization transactions: Medical/Surgical Pre-Authorization; Chemotherapy/Infusion Therapy Authorization; Durable Medical Equipment (DME); and Speech Therapy Authorization. Some of the changes will include the following:

• Only certain outpatient and office procedures will require authorization.
• Only certain drugs/infusions will require authorization, and it is no longer dependent on setting.
• Only certain DME items will require authorization.
• No authorization will be required for speech therapy.

Please refer to the Reminder: Updates to precertification requirements effective January 1, 2014 article in this edition of Partners in Health Update for more specific information about these changes.

For more information

To help you better understand these changes, new user guides will be made available soon that will describe these transactions in greater detail. We encourage you to review these new guides when they are published in the NaviNet Transaction Changes section of our Upcoming System and Process Changes site.

Announcements will be made on AmeriHealth NaviNet Plan Central and on our Provider News Center once the new guides are posted.

If you have any questions regarding the NaviNet transaction changes, please call the eBusiness Hotline at 215-640-7410 for providers in Pennsylvania and Delaware and at 609-662-2565 for providers in New Jersey.

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