As a reminder, AmeriHealth began to make changes to its office-based pathology network, as of January 1, 2018. These changes affect the credentialing of pathologists who perform services in the office setting and the HMO and PPO claim payment policies referenced below.
Closure of the office-based pathology network to new pathologists
We previously communicated to you on December 1, 2017, that the AmeriHealth provider network is closed for new office-based pathology providers effective January 1, 2018. This change applies to pathologists in the AmeriHealth service area (i.e., participating counties in New Jersey, Pennsylvania, Delaware, and Maryland) except when the pathologist meets the following condition:
A pathology provider is joining an existing participating hospital-based pathology group in a participating hospital in our service area (as identified above).
Note: Pathologists cannot be added to participating non-pathology practices as of January 1, 2018.
Affected claim payment policies for existing in-network pathologists
HMO policy
Effective April 1, 2018, AmeriHealth will not reimburse for pathology services according to the existing Claim Payment Policy #00.03.07u: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products. Claims submitted for pathology services that are billed by an office-based pathologist on or after April 1, 2018, will be denied consistent with this policy.
To view this existing HMO policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, select the Commercial tab, and type the policy name or number in the Search field.
PPO policyEffective April 1, 2018, AmeriHealth will update Claim Payment Policy #00.01.25aq: PPO Network Rules for Provision of Specialty Service for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services to prohibit billing and reimbursement for pathology services provided by office-based pathologists for PPO members. To view the updated PPO policy and the Limited Circumstances Procedure Code List, which were posted as a Notification on January 3, 2018, and will go into effect April 1, 2018, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial under Active Notifications. | Clarification for non-pathology specialists This change does not apply to providers in specialties other than pathology. Non-pathology specialties can continue to bill for certain pathology codes in the office setting as outlined in our PPO Network Rules for Provision of Specialty Service for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services policy. For a list of CPT® codes for which non-pathology specialists may be eligible for reimbursement, refer to the Limited Circumstances Procedure Code List in Attachment B3 of the PPO Network Rules policy. |
Why we are making these changes
AmeriHealth has decided to make these changes after an in-depth analysis of our HMO and PPO laboratory network and a review of our policies. Our current participating AmeriHealth HMO and PPO laboratory network provides sufficient coverage to our members and your patients. These policy changes will help to:
- reduce out-of-pocket expenses for our members;
- ensure consistency with industry standards and practices.
If you have any questions about these changes, please email us at
ahofficebasedpathology@amerihealth.com. Be sure to include your name, contact number, and provider ID number in your email.
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