2022 Provider Notifications
December 29, 2022
Winter issue of Connections now online (PDF)
Highlights include 2022 – 23 flu vaccinations, DHS-issued changes to the statewide preferred drug list (PDL) effective January 9, 2023, and more.
December 20, 2022
Benefit limit exception (BLE) process reminder (PDF)
As a reminder, the standard 2012 American Dental Association (ADA) claim form that accompanies the BLE form must include a diagnosis code.
December 8, 2022
Changes to the 2023 Statewide Preferred Drug List (PDL) (PDF)
The Pennsylvania Department of Human Services (DHS) will implement changes to the statewide preferred drug list (PDL) on January 9, 2023.
December 7, 2022
Inpatient (IP) claims and Medicare Part B billing recommendations (PDF)
Providers should use these recommendations when billing for IP claims when an AmeriHealth Caritas Pennsylvania member has Medicare Part A and B, but Medicare Part A has exhausted, or the member has Medicare Part B only.
November 17, 2022
Correction: new solution for online prior authorizations launch dates (PDF)
Effective November 21, 2022, AmeriHealth Caritas Pennsylvania is implementing a new system for providers to submit prior authorization requests for medical and behavioral health services.
November 17, 2022
Third-party liability and coordination of benefits reminder (PDF)
Before billing AmeriHealth Caritas Pennsylvania when there is a primary insurer, providers are required to bill the primary insurer first and obtain an Explanation of Benefits statement from the primary insurer.
October 27, 2022
2022 – 2023 flu vaccination (PDF)
In preparation for the onset of flu season, while still facing COVID-19, we are asking you to encourage your patients to get their flu shot.
October 12, 2022
Update: Naloxone take-home distribution by federally qualified health centers (FQHCs) and rural health clinics (RHCs) (PDF)
AmeriHealth Caritas Pennsylvania is following guidelines outlined in Medical Assistance Bulletin (MAB) 08-22-19 around submitting claims for a take-home supply of naloxone.
October 6, 2022
Adult vaccine procedure code updates and additions (PDF)
Effective on and after August 29, 2022, AmeriHealth Caritas Pennsylvania providers should utilize the codes and the fee schedule for adult vaccines as outlined in Medical Assistance bulletin 01-22-42.
September 30, 2022
Change in care management services and utilization management for NICU or special care nursery (PDF)
Effective November 30, 2022, care management and utilization management services for members admitted to the NICU or special care nursery will be coordinated and provided by and through the AmeriHealth Caritas PA care management team and Neonatal Care Coordination program.
September 29, 2022
Reinstatement of prior authorization requirements for shift care services for members under 21 years of age (PDF)
Effective December 1, 2022, AmeriHealth Caritas Pennsylvania will reinstate the prior authorization requirements for existing shift care services provided to members under the age of 21.
September 20, 2022
Implicit bias training (PDF)
AmeriHealth Caritas Pennsylvania has partnered with the March of Dimes to provide a webinar on implicit bias.
September 15, 2022
Surgical procedure anatomical modifier requirement (PDF)
Beginning October 15, 2022, AmeriHealth Caritas Pennsylvania will require providers to follow standard published coding guidelines which include the use of the appropriate anatomical modifier.
September 14, 2022
Additions to the Medical Assistance fee schedule for monkeypox laboratory testing and vaccines (PDF)
AmeriHealth Caritas Pennsylvania will follow the guidelines issued on July 26, 2022, by the Department of Human Services (DHS) Medical Assistance Bulletin (MAB) 01-22-41 outlining the addition of newly created Current Procedural Terminology (CPT) codes for monkeypox laboratory testing and vaccines.
September 12, 2022
Reminder: requirement to utilize in-network laboratory service providers (PDF)
Quest Diagnostics is the preferred in-network independent lab provider for AmeriHealth Caritas Pennsylvania. However, a provider may also use a participating in-network hospital outpatient laboratory for lab testing services.
September 8, 2022
2022 AmeriHealth Caritas Pennsylvania Dental Provider Supplement now available online (PDF)
Updates and topics include dental services covered when medically necessary, how to approach missed appointments, updated language around retrospective review, and more.
September 7, 2022
Billing for repairs to home accessibility durable medical equipment (DME) (PDF)
Please refer to this reminder about which home accessibility DME services are covered by AmeriHealth Caritas Pennsylvania and which ones require prior authorization.
August 31, 2022
Check member eligibility due to changes in HealthChoices membership starting September 1, 2022 (PDF)
Over 400,000 individuals (statewide) did not select a new MCO. DHS auto-assigned them to one of the PH MCO plans available to them in their specific zone. Therefore, there is a chance that a member could have been assigned to another PH MCO through the revised DHS auto-assignment process.
August 25, 2022
Changes to membership in HealthChoices starting September 1, 2022 (PDF)
If an AmeriHealth Caritas Pennsylvania member comes to your office without an ID card, please do not turn them away for service. Check their eligibility by either calling the AmeriHealth Caritas Pennsylvania automated IVR system (1-800-521-6007) or through the NaviNet eligibility search.
August 16, 2022
Update: prior authorization for septoplasty, submucous resection (PDF)
Prior authorization is required for septoplasty, submucous sesection (CPT code 30520).
August 9, 2022
Updated and enhanced remark codes on Explanation of Benefits (EOBs) (PDF)
Starting in the month of August, you will see new remark codes on your Explanation of Benefits (EOBs).
July 27, 2022
Ordering and dispensing blood pressure monitors (PDF)
Providers who believe their patients would benefit from an automatic blood pressure monitor (A4670) should give them a prescription that can be taken to any participating network pharmacy.
July 26, 2022
Summer issue of Connections now online (PDF)
Highlights include: 2022 updated Provider Manual is now available online, 2022 HCBS Provider Claims Filing Instructions are now available online, and more.
July 6, 2022
Important change to blood lead reference value (PDF)
The blood lead reference value for children is being updated from 5 μg/dL to 3.5 μg/dL
June 28, 2022
Updated 2022 Provider Manual now available online (PDF)
Updates and changes include: update to notification process following a pharmacy prior authorization denial, updated language around complaints, grievances and fair hearings, changes to the paper credentialing application process, and more.
June 23, 2022
2022 recommended childhood and adolescent immunization schedule now online (PDF)
The 2022 recommended immunization schedule for children and adolescents age 18 years or younger can be found in the Department of Human Services (DHS) Medical Assistance Bulletin (MAB) 99-22-03.
June 15, 2022
Clarification: continued stay coverage, review, and billing reminders (PDF)
A claim can be submitted once authorization is approved with no need to hold the claim for the NFCE determination.
June 9, 2022
Changes to Pennsylvania’s HealthChoices physical health plans (PDF)
Effective September 1, 2022, the Pennsylvania Department of Human Services is changing which physical health managed care organizations are available for Medical Assistance consumers.
June 8, 2022
Delayed launch of new prior authorization system (PDF)
The June 3, 2022, launch of the new prior authorization system is delayed. Information regarding a new launch date will be communicated at a later date.
June 1, 2022
Change to adult immunization/immune globulin fee schedule (PDF)
Effective August 1, 2022, the AmeriHealth Caritas Pennsylvania adult immunizations/immune globulin fee schedule will be updated.
May 18, 2022
Take the annual mandatory fraud, waste, and abuse training (PDF)
All network providers must complete and attest to completion of mandatory FWA training on an annual basis, as required by our contract with the Pennsylvania Department of Human Services (DHS).
May 11, 2022
Continued stay coverage, review, and billing reminders (PDF)
Coverage policy reminder for nursing facilities.
May 11, 2022
June 2022 formulary changes (PDF)
Some products will be removed from the AmeriHealth Caritas Pennsylvania drug formulary on June 15, 2022. Members currently receiving those products will require a new prescription for an alternative product before that date.
May 11, 2022
2022 medical provider claims filing instructions now available (PDF)
AmeriHealth Caritas Pennsylvania is pleased to announce the availability of the 2022 medical provider claims filing instructions.
April 5, 2022
New solution for online prior authorizations (PDF)
Effective June 3, 2022, a new system is being implemented for providers to submit prior authorization requests for medical and behavioral health services.
March 30, 2022
Update to home accessibility durable medical equipment (DME) coverage and billing (PDF)
AmeriHealth Caritas Pennsylvania will follow the Department of Human Services (DHS) guidelines released in Medical Assistance Bulletin (MAB) 25-21-01 regarding the coverage of home accessibility durable medical equipment and procedure for obtaining an 1150 administrative waiver in the fee-for-service delivery system.
March 23, 2022
Update to Modifier 25 policy (PDF)
Effective April 1, 2022, AmeriHealth Caritas Pennsylvania is revising the reduced payment policy for certain Evaluation and Management (E/M) procedure codes billed with Common Procedure Terminology (CPT) modifier 25 when services occur within the minor procedure Global Surgery time frames as defined by the Centers for Medicare & Medicaid Services (CMS).
March 21, 2022
March issue of our provider newsletter, Connections, now online (PDF)
Highlights include a new Medical Assistance bulletin (MAB) announcing newly created Current Procedural Terminology (CPT) codes for the administration of SARS-CoV-2 vaccines, claims filing instructions, and more.
March 21, 2022
Our 2022 Quality Enhancement program manual is now available (PDF)
The 2022 Quality Enhancement Program (QEP) manual is now available for our primary care providers.
March 9, 2022
Introduction of a new procedure code (T1019) for Electronic Visit verification (EVV) reporting for Personal Care Services (PCS) (PDF)
AmeriHealth Caritas Pennsylvania will follow the Pennsylvania Department of Human Services (DHS) guidelines and will implement the new procedure code T1019 for reporting EVV PCS services for 15-minute units.
February 1, 2022
NaviNet upgrades for Condition Optimization Program (formerly Intensive Case Management Program) (PDF)
Effective April 1, 2022, AmeriHealth Caritas Pennsylvania is upgrading the NaviNet portal to enhance the Retrospective and Prospective Outreach Programs.
January 10, 2022
CPT codes for pediatric Pfizer, Inc. SARS-CoV-2 vaccine (PDF)
AmeriHealth Caritas Pennsylvania will follow the guidelines issued in MAB 01-21-51 addressing CPT codes for the administration of pediatric SARS-CoV-2 Pfizer, Inc. vaccine. Additionally, we are also following guidelines issued in MAB 01-21-55, outlining CPT codes for the administration of booster doses of the SARS-CoV-2 vaccines.
January 3, 2022
Update: formulary changes (PDF)
Some products will be removed from the AmeriHealth Caritas Pennsylvania drug formulary. Members currently receiving these products will require a new prescription for an alternative product before February 1, 2022.