As you know, all AmeriHealth New Jersey Medicare Advantage members were migrated to the new operating platform on January 1, 2015. AmeriHealth New Jersey commercial members will be migrated to the new platform between September 1, 2015, and October 1, 2015. There are changes to the application of medical and claim payment policies that will apply to migrated members on the new platform.

AmeriHealth policies will be used for adjudication 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 New Jersey members as described below. Please note the required fields that must be completed in order to be processed on the new platform.

The information below highlights some differences in claims processing and outcomes between the two systems, and the results of a recent analysis of rejection rates post migration.

Multiple Surgical Reduction Guidelines

For professional providers, the calculation method used in applying Multiple Surgical Reduction Guidelines for 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 old platform. This may result in a different claim outcome.

To review these policies, which reflect and disclose the different calculations being used with two claims platforms, refer to our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select the Commercial or Medicare Advantage tab from the top of the page, depending on the version of the policy you?d like to view. Then type the policy name or number in the Search field:

• Commercial: #11.00.10s: Multiple Surgical Reduction Guidelines;
• Medicare Advantage: #MA11.032b: Multiple Surgical Reduction Guidelines.

Clinical Relationship Logic

Clinical Relationship Logic, or Code-to-Code Edits (e.g., incidental, integral, component, and mutually exclusive), applied to services reported on a CMS-1500 claim form or electronic equivalent may differ for AmeriHealth New Jersey member claims depending on whether the claim is processing on the old 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 New Jersey members processed on the new platform. Clinical Relationship Logic applied to professional claims will be applied according to the following:

• On the old platform (i.e., for AmeriHealth New Jersey commercial members who have not yet been migrated). Clinical Relationship Logic applied to professional claims for members processed on the old platform will continue to be disclosed through the current Clear Claim Connection^TM tool, which is available on the NaviNet^® web portal within the Claim Inquiry and Maintenance transaction or on the Clear Claim Connection page on the AmeriHealth New Jersey website.
• On the new platform (i.e., for migrated members). Clinical Relationship Logic applied to professional claims for AmeriHealth New Jersey members processed on the new platform is available on the AmeriHealth New Jersey website.

Correctly submitting UB-04 claim forms with OPL and COB

When a paper claim is submitted and Other Party Liability (OPL) or Coordination of Benefits (COB) is involved, it is imperative that all applicable fields are completed correctly on the UB-04 claim form, including the following:

• Field Location 54 (FL54). FL54 is a required field when the indicated payer (other insurance) has paid an amount to the provider towards this bill. Report ?0.00? if there is no payment made by the health plan or payment was applied to the member?s coinsurance or deductible.
• Field Locations 39, 40, 41 (FL39, FL40, FL41). FL39, FL40, and FL41 are required fields when there is a value code and amount that applies to the claim, specifically where Medicare is primary and coinsurance or a deductible applies.
• Multi-page claims. Per the National Uniform Billing Committee (NUBC), all claim-level data must be reported on each page of the UB-04 claim form. Line-level data will be unique on each page of the claim, and total charges for the claim (FL47, line 23) should be reported only on the last page.

Common claim rejections on the new platform

The following is a list of reasons why claims are rejected on the new platform.

• NPI and trading partner are not affiliated. The provider?s National Provider Identifier (NPI) and the trading partner are required to be linked in the new system; otherwise, the trading partner is not authorized to submit electronic claims on the provider?s behalf and the claims will reject. Contact your clearinghouse or billing vendor for instructions on how to affiliate. If you are your own trading partner, go to the EDI section of our website for more information.
• NAIC code ? Submit to the correct payer. Ensure that you submit claims with the appropriate NAIC code, as identified in the Payer Information column on our payer ID grids and in accordance with the member?s coverage. Refer to the payer ID grids on our website.
• Member not found:
  • Subscriber ID invalid. Providers must submit the most current member ID number based on the member?s coverage at the time of service. Please refer to the article, Use the full member ID number when billing for service, on the new AmeriHealth New Jersey member ID cards in this edition of Partners in Health Update^SM for more information on checking ID cards and verifying member eligibility at every visit.
  • Names misspelled or name variations. A member?s name must be spelled as it appears on the member ID card. Variations in name spellings and punctuation will cause claims to reject (e.g., D?Angelo vs. Dangelo).
• Claim submitted without taxonomy code. The provider?s taxonomy code must be billed with the corresponding NPI and submitted at the billing provider level. Providers associated with more than one specialty group are required to submit the correct NPI and correlating taxonomy code to ensure correct claims processing. Sending claims with incorrect taxonomy codes could cause payment delays or cause claims to be paid incorrectly. Detailed information and examples on how to correctly submit taxonomy codes can be found in the article, Guidelines for billing with taxonomy codes and use of NPI on claims in this edition of Partners in Health Update.
• Missing referring provider. The referring provider is required on all claims when the place of service is 81, a professional independent clinical lab.
• Missing procedure description. A service line description is required for all non-specific procedure codes submitted on a claim. Non-specific procedure codes include not otherwise classified [NOC]; unspecified; other; miscellaneous; prescription drug, generic; or prescription drug, brand name.
• Code set validations. Valid codes, including HCPCS, CPT^®, diagnosis, and revenue codes and procedure code modifiers, are required for all claims. Submitted claims containing invalid codes or codes with termination dates effective prior to or on the date of service will not be processed.

For the most up-to-date information about our upcoming transition of AmeriHealth New Jersey commercial members to the new platform, we encourage you to visit the System and Process Changes section of the Provider News Center.

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