As early as September 27, 2013, you will begin to see changes to the NaviNet web portal that will affect the way you do business with AmeriHealth. Many transactions will be enhanced or updated, as described in this article. Some will also be retired, as communicated in the June 2013 edition of
Partners in Health UpdateSM.Note: When conducting transactions from AmeriHealth NaviNet Plan Central, search results will include eligibility, benefits, and claims data information only for members covered under AmeriHealth plans.The following information details the transactions that will be affected by the upcoming changes:Accepted Claim Status Inquiry. This transaction will be renamed Claim Status Inquiry. The data display will be upgraded to enhance the claims review process. In addition, when searching for claims, the tax ID number will no longer be one of the search criteria.
Capitation:?? Primary care physicians (PCP). As early as November 1, 2013, paper rosters will no longer be mailed to PCPs for AmeriHealth Pennsylvania members who have been migrated to our new platform. Additionally, all capitation payments issued to PCPs will only be made through electronic funds transfer (EFT) for migrated AmeriHealth members. Paper checks and paper rosters will continue to be mailed for non-migrated members.
?? Specialists. The CAP Rosters transaction will be expanded to include electronic rosters for our capitated specialty providers: radiology, laboratory, and physical therapy. As early as January 1, 2014, paper rosters will no longer be mailed to specialty providers for AmeriHealth Pennsylvania members who have been migrated to our new platform. Additionally, all capitation payments issued to specialty providers will only be made through EFT for migrated AmeriHealth Pennsylvania members. Paper checks and paper rosters will continue to be mailed for non-migrated members.
Note: PCPs and specialists not yet enrolled for EFT must register through NaviNet no later than October 1, 2013, to ensure no payment disruption. Please refer to the EFT User Guide, available on NaviNet Plan Central under Administrative Tools & Resources. If providers do not register for EFT, they will not receive capitation payments for migrated AmeriHealth Pennsylvania members.
Claim INFO Adjustment Submission. Beginning September 27, 2013, the Plan Transactions menu will no longer include this transaction as a stand-alone option. If a provider accesses a paid or denied claim through the new Claim Status Inquiry transaction, they can expect the following:
?? For AmeriHealth members on the current platform: Providers will be offered a link to Claims INVESTIGATION.This link will provide the same claims adjustment tools (including the ability to edit a claim) that are available today.
?? For AmeriHealth Pennsylvania members on the new platform: For AmeriHealth Pennsylvania members who have been migrated to the new platform, providers will be offered a link to Claims INVESTIGATION. This link will allow providers to submit an inquiry for an individual claim, but it does not permit claim editing.
Clear Claim Connection
TM. This transaction is a Web-based reference tool designed to evaluate code combinations during the auditing of professional claims. By accessing the tool, the user can view the justifications and clinical rationale on how a professional claim processes. On September 27, 2013, this transaction will be disabled. It will be released again in April 2014.
Clinical Alerts and Clinical Care Reports. Clinical Alerts and Clinical Care Reports will be temporarily disabled in September. The Clinical Alerts feature is a clinical practice tool that alerts providers when their patients have not received a recommended service. Currently, Clinical Alerts are only available to PCPs, cardiologists, OB/GYNs, and endocrinologists. Beginning in December, access to Clinical Alerts will be re-established and will be expanded to all provider specialties.
In addition, both Clinical Alerts and Clinical Care Reports will be available in a new location on AmeriHealth NaviNet Plan Central. Currently, these features are available by searching for a member and selecting the colored flag on the Member Eligibility and Benefits Inquiry screen. Beginning in December, you will be able to access Clinical Alerts and the Clinical Care Report for a member through links on the Eligibility Detail screen.
Additional information on the current functionality of Clinical Alerts can be found in the user guide available in the Administrative Tools & Resources section of AmeriHealth NaviNet Plan Central. Later this year, a new guide will be available and will reflect the outlined changes.Your designated Security Officer will continue to control user access and permissions for both of these resources through the User Management transaction, which is available by selecting NaviNet Central and then NaviNet Administration.
Eligibility and Benefits Inquiry. The search criteria and data display will be enhanced to facilitate improved access to specific member eligibility and benefits information. As we migrate AmeriHealth Pennsylvania members to the new claims operating platform, their eligibility and benefits information will be displayed differently in NaviNet. For AmeriHealth Pennsylvania members who are migrated to the new platform, links to benefit categories will be available to help direct providers to specific member information more easily.
Note: AmeriHealth Pennsylvania members who have been migrated to the new platform will be issued a new ID card, which will contain a new member ID number. Migrated AmeriHealth Pennsylvania members will be issued a single member ID number that applies to both the subscriber and his or her dependents. Because member ID numbers for all AmeriHealth Pennsylvania members will be changing over the next couple of years, it is imperative that all providers ask members for their current ID card at each visit and make a copy for their records.
Encounter Submission. When submitting encounter data through NaviNet, PCPs participating in our managed care networks will be required to report additional information relating to the member's visit (similar to the HCFA-1500 form). This change is compliant with new Health Care Reform requirements. We will provide more specific details in a future edition of
Partners in Health UpdateSM.
Fee Schedule Inquiry. This transaction will be temporarily disabled as we continue efforts to migrate AmeriHealth Pennsylvania members to the new operating platform. The Fee Schedule Inquiry transaction is scheduled to be re-introduced in the first quarter of 2014. Additional information will be provided in a future edition of
Partners in Health UpdateSM.
Online SOR. During the transition to the new operating platform for AmeriHealth Pennsylvania members, AmeriHealth will be working with you in a dual claims-processing environment until all of these members have been migrated to the new platform. The Online SOR Inquiry transaction will continue to display remittance information for claims that are processed on the current platform. However, a new transaction called EOB and Remittance Inquiry will provide remittance information for AmeriHealth Pennsylvania member claims that are processed on the new platform. Once the AmeriHealth Pennsylvania member migration is complete in 2015, all claim payment information for these members will be available through the new EOB and Remittance Inquiry transaction.
Provider Change Form. This transaction will be temporarily disabled while we transition AmeriHealth Pennsylvania members to the new platform. To make provider record changes during the time, you will need to contact your Network Coordinator.
Referral Inquiry. The Referral Inquiry transaction will be enhanced to promote easier navigation to member referrals for facilities, PCPs, OB/GYNs, and other specialists.
Referral Submission (medical and OB/GYN). The Referral Submission and OB/GYN Referral Submission transactions will be consolidated into a single transaction. The search criteria and data display will be enhanced to promote a more simplified method for PCPs and OB/GYNs when submitting referrals for AmeriHealth members. The list of requested services in the new transaction will be a more generalized list of services to accommodate all referral requests. Both the comments field and the Referral Log will be eliminated.
Providers will be able to check the status of their referral submissions through the Referral Inquiry transaction. Providers will also continue to have the ability to back-date referral submissions up to 90 days.If you have any questions regarding upcoming NaviNet changes, please call the eBusiness hotline at [
]215-640-7410[] for Pennsylvania and Delaware providers or at [
]609-662-2565[] for New Jersey providers.[
NaviNet® is a registered trademark of NaviNet, Inc.
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