2020 Provider Notifications
December 20, 2020
Gender-specific editing billing reminder (PDF)
AmeriHealth Caritas Pennsylvania follows all current and correct coding guidelines established by the Centers for Medicare and Medicaid Services (CMS) and the Department of Human Services (DHS) relating to gender-specific editing.
December 17, 2020
Our December issue of Connections is now available online (PDF)
A Provider’s Link to AmeriHealth Caritas Pennsylvania. We are pleased to announce that on January 1, 2021, we will be changing our name in the northeast region from AmeriHealth Caritas Northeast to AmeriHealth Caritas Pennsylvania.
December 8, 2020
Delay in Home and Portable Oxygen Therapy Policy Change (PDF)
As we continue to carefully monitor and follow all the Pennsylvania state emergency rules regarding the COVID-19 pandemic, this scheduled change will be delayed until a valid disaster declaration authorized by the Governor for the COVID- 19 virus is no longer in effect.
December 2, 2020
Statewide Preferred Drug List (PDL) Update (PDF)
The Pennsylvania Department of Human Services (DHS) will implement changes to the statewide preferred drug list (PDL) on January 5, 2021.
November 30, 2020
After-Hours Bonus Discontinued (PDF)
Effective December 15, 2020, AmeriHealth Caritas Pennsylvania will no longer reimburse capitated and fee-for-service primary care practitioners a bonus payment for member visits conducted during regularly scheduled evening, weekend, or holiday hours.
November 20, 2020
ADHD Telephonic Services (PDF)
Practitioners that have provided any of the qualified services listed for eligible AmeriHealth Caritas Pennsylvania members should submit a claim for HEDIS® reporting purposes.
November 17, 2020
Updates: Non-Obstetrical Pelvic Ultrasounds Policy and Obstetrical Ultrasounds Examination Policy (PDF)
Effective January 18, 2021, AmeriHealth Caritas Pennsylvania will reimburse providers for the transvaginal ultrasound procedure at 100% of the allowed amount, and for the transabdominal ultrasound procedure at 50% of the allowed amount, when both services are rendered by the same provider to the same patient on the same day and during the same session.
November 13, 2020
Emergency Services Level of Care Review Policy (PDF)
Effective January 12, 2021, AmeriHealth Caritas Pennsylvania will review and potentially recover reimbursement for Emergency Department (ED) professional and facility claims billing Evaluation and Management (E/M) services classified as Level 4 (CPT Codes: 99284/G0383) or Level 5 (CPT Codes: 99285/G0384) when there is inconsistency between the level of services billed and the severity of diagnosis.
November 12, 2020
Updated 2020 Provider manual is now available online (PDF)
AmeriHealth Caritas Pennsylvania announces the availability of the 2020 Provider Manual.
November 3, 2020
Update to Performant’s Retrospective Outpatient Services Audit (PDF)
As announced in the notification dated September 28, 2020, from AmeriHealth Caritas Pennsylvania, Performant Recovery Inc. has been engaged to perform retrospective claim payment audits on outpatient surgical claims beginning December 1, 2020.
October 30, 2020
Formulary changes (PDF)
Effective December 1, 2020, some products will be removed from the AmeriHealth Caritas Pennsylvania drug formulary.
October 22, 2020
T1015 billing update (PDF)
Effective December 23, 2020, AmeriHealth Caritas Pennsylvania will begin following updated T1015 billing guidelines. Claims submitted after December 23, 2020, not following these guidelines will be denied.
October 13, 2020
Preparing for the onset of the 2020-2021 flu season (PDF)
As we prepare for flu season, it is critical this year to encourage your patients to get their flu shots.
October 6, 2020
Change in prior authorization requirements (PDF)
AmeriHealth Caritas Pennsylvania is announcing some changes to services that require prior authorization.
October 5, 2020
Home and Portable Oxygen Therapy Policy, other DME monthly rental clarification (PDF)
This provider notice offers guidance on the conditions and criteria that must be met to obtain prior authorization by AmeriHealth Caritas Pennsylvania for home and portable oxygen therapy. This policy will be effective on December 15, 2020; however we will continue to evaluate the COVID-19 pandemic and state emergency rule as to the possible impact of the policy effective date.
September 28, 2020
Introduction to Performant’s Retrospective Outpatient Services Audit (PDF)
In a continuing effort to manage health care costs, AmeriHealth Caritas Pennsylvania has engaged Performant Recovery Inc. to perform retrospective claim payment audits.
September 1, 2020
Modifier 25 Policy (PDF)
Effective November 1, 2020, AmeriHealth Caritas Pennsylvania will pay a reduced reimbursement of certain Evaluation and Management (E/M) procedure codes billed with Current Procedure Terminology (CPT) modifier 25 when services occur within the minor procedure Global Surgery timeframes as defined by the Centers for Medicare and Medicaid Services (CMS).
September 1, 2020
New Multiple Therapy Reduction Policy (PDF)
In alignment with the Centers for Medicare and Medicaid Services (CMS) reimbursement policy on Multiple Therapy Procedures, AmeriHealth Caritas Pennsylvania will follow the reimbursement policy for multiple therapy services provided on a single service date, for the same individual, by the same provider (as identified by their NPI), effective November 1, 2020.
August 26, 2020
Billing updates to childhood weight management services (PDF)
Effective with date of service May 26, 2020, and beyond, AmeriHealth Caritas Pennsylvania will follow the billing guidelines outlined in Medical Assistance Bulletin 99-20-02 recently released by the Department of Human Services (DHS) regarding Childhood Weight Management Services (CWMS).
August 18, 2020
Change in Prior Authorization Policy for DME Rental Equipment (PDF)
Effective October 18, 2020, AmeriHealth Caritas Pennsylvania is changing its prior authorization policy regarding durable medical equipment (DME).
August 10, 2020
Care Gap changes to align with HEDIS® measures (PDF)
AmeriHealth Caritas Pennsylvania has streamlined its Care Gaps methodology to bring you a more manageable data set.
July 31, 2020
Our July issue of Connections is now available (PDF)
AmeriHealth Caritas Pennsylvania are pleased to announce the availability of the latest issue of our provider newsletter, Connections! We hope your practice finds this issue educational and helpful.
July 30, 2020
Paper Panel Roster reports to be discontinued (PDF)
As part of our ongoing effort to share information via sustainable means, we are discontinuing the practice of providing paper copies of Panel Roster reports, effective September 1, 2020.
July 30, 2020
EDI billing reminder — submit appropriate information for coordination of benefits (PDF)
When billing Electronic Data Interchange (EDI) 837 coordination of benefit services to AmeriHealth Caritas Pennsylvania as a secondary payor for a member that has traditional Medicare or a Medicare Advantage plan (including AmeriHealth Caritas VIP Care), please remember to indicate the appropriate primary insurer. Claims submitted indicating the primary payor incorrectly as a commercial carrier rather than Medicare may be delayed or processed incorrectly.
July 1, 2020
New: Pre-admission Testing for Three/One Day Window policy (PDF)
Effective September 1, 2020, outpatient services that are clinically related and furnished within three days of an inpatient admission must be included as part of inpatient services for billing purposes.
June 15, 2020
New: Ambulatory Surgery Center Procedures policy, August 2020 (PDF)
Effective August 15, 2020, prior authorization is not required for some procedures performed in an in-network Ambulatory Surgery Center.
June 15, 2020
New: Anesthesia Services for Gastrointestinal Endoscopy policy, August 2020 (PDF)
Effective August 15, 2020, AmeriHealth Caritas Pennsylvania is updating the policy around anesthesia services for gastrointestinal endoscopies.
June 15, 2020
Updated: Lowest Cost Site of Care Medical Pharmacy policy, August 2020 (PDF)
Certain drugs can be safely administered in an in-network infusion center, network provider office, or in a home setting. Reimbursement for administration of these drugs at a hospital-based facility is available only if specific criteria are met. Providers must receive prior authorization for the administration of these drugs.
June 15, 2020
Update: Outpatient Surgical Procedures policy, August 2020 (PDF)
Effective August 15, 2020, some surgical procedures should be performed in an outpatient surgical center unless certain criteria are evident.
June 1, 2020
Therapy telemedicine date extension (PDF)
AmeriHealth Caritas Pennsylvania will continue to cover the services outlined in the April 17, 2020, notice while a valid disaster declaration by the Governor related to the COVID-19 virus remains in effect.
May 28, 2020
COVID-19 telemedicine update (PDF)
AmeriHealth Caritas Pennsylvania will continue to cover the services outlined in the March 19th notice while a valid disaster declaration by the Governor related to the COVID-19 virus remains in effect.
May 19, 2020
AmeriHealth Caritas Pennsylvania to follow DHS Provider Quick Tips #241 and #243 during COVID-19 pandemic (PDF)
Quick Tips #241 addresses changes to prior authorization requirements and Quick Tips #243 outlines some important reminders for claims submitted for dates of service March 1, 2020, and after.
May 18, 2020
New electronic payment methods through Change Healthcare and ECHO Health Inc. (PDF)
As of July 20, 2020, AmeriHealth Caritas Pennsylvania will partner with Change Healthcare and ECHO Health Inc. to provide additional electronic payment methods.
May 12, 2020
DHS guidelines for DME prior authorization during COVID-19 outbreak (PDF)
To reduce the burden on providers and patients during the COVID-19 pandemic, AmeriHealth Caritas Pennsylvania will follow DHS guidelines regarding the authorization requirements for durable medical equipment (DME).
May 1, 2020
EOB code update, June 2020 (PDF)
AmeriHealth Caritas Pennsylvania is transitioning to a new claim editing vendor. Therefore, you may begin to see additional Explanation of Benefits (EOB) explanation codes on zero paid lines.
April 30, 2020
DHS guidelines for CT scans during COVID-19 pandemic (PDF)
To reduce the burden on providers and patients during this time, AmeriHealth Caritas Pennsylvania will follow the guidelines recently released by the Department of Human Services regarding the authorization requirements for CT scans.
April 24, 2020
FCC telehealth funding notice (PDF)
Under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, funds will be made available to help providers with purchasing the connectivity and devices needed to render care remotely.
April 17, 2020
Therapy telemedicine April notice (PDF)
AmeriHealth Caritas Pennsylvania will cover telemedicine as a delivery method for outpatient physical, occupational, and speech therapy.
April 7, 2020
Hydroxychloroquine limits and ranitidine recall (PDF)
AmeriHealth Caritas Pennsylvania will follow the Department of Human Services (DHS) guidelines regarding the effort to prevent potential shortages of hydroxychloroquine. The U.S. Food and Drug Administration has also requested a manufacturer’s market withdrawal of ranitidine.
March 23, 2020
Coronavirus (COVID-19) Account Executive notice (PDF)
Changes to Account Executive support systems in response to the coronavirus (COVID-19).
March 19, 2020
Telemedicine care for coronavirus (COVID-19) (PDF)
Effective from March 13, 2020, through June 12, 2020, AmeriHealth Caritas Pennsylvania will use updated guidelines for the use of telemedicine as a delivery method for medically necessary health care services.
March 12, 2020
APR-DRG version 37 update (PDF)
On April 2, 2020, AmeriHealth Caritas Pennsylvania will replace APR-DRG version 36 with version 37 for all inpatient acute care encounters with a discharge date on or after October 1, 2019.
March 10, 2020
Coronavirus disease (COVID-19) announcement (PDF)
The CDC is closely monitoring the outbreak of a respiratory disease caused by a new coronavirus that was first detected in Wuhan City, Hubei Province, China, and continues to spread.
February 19, 2020
MQEP postpartum correction (PDF)
The postpartum component of the 2020 Maternity Quality Enhancement Program (MQEP) Quality Performance program has changed from rendering the postpartum visit within 21-56 days after delivery to now comply with the HEDIS revised timeframe of rendering the visit from 7–84 days after delivery.
February 3, 2020
HCPCS medication codes announcement (PDF)
AmeriHealth Caritas Pennsylvania (PA) is using the same prior authorization guidelines as required by Pennsylvania Department of Human Services (DHS) for drugs included in the statewide preferred drug list (PDL).