This article is a reminder that effective January 1, 2015, we are introducing changes related to the application of medical and claim payment policies, as well as clinical relationship logic, for AmeriHealth Medicare Advantage business.
Policy changes
Medical and claim payment policies that currently apply to both commercial and Medicare Advantage business will be separated into two unique policy portfolios: one for commercial business and one for Medicare Advantage business.
The new Medicare Advantage policy portfolio will become effective January 1, 2015; notifications for these policies will be available on the AmeriHealth Medical Policy Portal by October 1, 2014. This policy portfolio will be based on Medicare coverage guidance as well as additional AmeriHealth medical and claim payment policy determinations.
Note: The existing policy portfolio will continue to apply to commercial business.
Clinical relationship logic (procedure code-to-procedure code edits)
Effective January 1, 2015, the following will be applied to claims submitted on the CMS-1500 claim form or through the 837P transaction for Medicare Advantage HMO members:
- Medicare?s National Correct Coding Initiative (NCCI) editing;
- other clinical relationship logic, which is based on procedure code editing standards.
For more information
Additional information about these changes will be provided in the October edition of Partners in Health UpdateSM.
Stay up-to-date on policy activity by visiting the Medical Policy Portal and selecting Accept and Go to Medical Policy Online. You can also view policy activity using the NaviNet® web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy. Be sure to check back often, as the site is updated frequently.
Coming soon: A new look for the Medical Policy Portal
In addition to accommodating the changes related to the separation of unique commercial and Medicare Advantage policy portfolios, the Medical Policy Portal is receiving a face lift. The updated portal will offer new navigation along the top and bottom left of the page, which enables users to easily find and access the separate policy portfolios for commercial and Medicare Advantage business, as well as the policy portfolio for Medicare Advantage business.
Later this month, go to the Medical Policy Portal and select Accept and Go to Medical Policy Online to see the changes and review the Policy Notifications for those new policies that go into effect on January 1, 2015.
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