As you know, we are in the process of migrating AmeriHealth Pennsylvania
members to a new claims processing platform. As a result, there will be changes
to the enforcement of medical and claim payment policy for these members.
AmeriHealth policies will be enforced on both the current and new claims
processing platforms; however, some differences in claims processing and
outcomes between the two systems may occur for AmeriHealth Pennsylvania members
as described in the following.
[
]Multiple Surgical Reduction Guidelines[
]
For professional providers, the calculation method used in applying Multiple
Surgical Reduction Guidelines for AmeriHealth Pennsylvania members on the new
platform will be based on the procedure reported "Allowed Amount" and not the
derived "Surgical Ranking," which is used on the current platform.
Please review the Policy Notification for Claim Payment Policy #11.00.10:
Multiple Surgical Reduction Guidelines, which will be available on the [
Medical Policy portal] after August 2, 2013. This policy, which will
become effective November 1, 2013, has been updated to reflect this change and
to disclose the different calculations being used within the two claims
platforms.
[
]Clinical Relationship Logic[
]
Clinical Relationship Logic, or Code to Code Edits (e.g., incidental, integral,
component, mutually exclusive, etc.), applied to services reported on a
CMS-1500 claim form or electronic equivalent may differ for AmeriHealth
Pennsylvania members, depending on whether the claim is processing on the
current or new platform. The McKesson ClaimCheck[
]?[] product will
not be used on the new platform.
Clinical Relationship Logic, which is based on national standards, will be
applied to claims for AmeriHealth Pennsylvania members processed on the new
platform. Clinical Relationship Logic applied to professional claims will be
disclosed according to the following:
On the current platform. Clinical Relationship Logic applied to professional
claims for members processed on the current platform will continue to be
disclosed through the current AmeriHealth Clear Claim
Connection[
]TM[] tool, which is available on the
NaviNet[
®] web portal or on the [
]AmerHealth[] website.
On the new platform. Clinical Relationship Logic applied to professional claims
for AmeriHealth Pennsylvania members processed on the new platform will be made
available on the AmeriHealth [
]Medical Policy[] website.
For the most up-to-date information about our transition to a new claims
processing platform for AmeriHealth Pennsylvania members, we encourage you to
frequently visit our [
]Upcoming System and Process Changes[] website. At this one central
location, we will continue to provide more detailed information as it becomes
available about our platform transition for AmeriHealth Pennsylvania members.
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NaviNet® is a registered trademark of
NaviNet, Inc.
]