1 Quick Reference Provider Precertification/ Notification Requirements Important Phone Numbers Revenue Codes New York NYPEC healthplus.amerigroup.com
2 Easy access to precertification/notification requirements and other important information For more information about requirements, benefits and services, visit our provider website to get the most recent, full version of our provider manual. If you have questions about this Quick Reference Card (QRC) or recommendations to improve it, call your local Provider Relations representative. We want to hear from you and improve our service so you can focus on serving your patients! Precertification/notification instructions and definitions Request precertification and give us notification: n Online: healthplus.amerigroup.com n By phone: n By fax: Fax behavioral health information to Precertification the act of authorizing specific services or activities before they are rendered or occur. This is also known as prior authorization (PA). Notification telephonic, fax or electronic communication received from a provider to inform us of your intent to render covered medical services to a member. n Give us notification prior to rendering services outlined in this document. n For emergency or urgent services, give us notification within 24 hours or the next business day. For code-specific requirements for all services, visit healthplus.amerigroup.com/providers and select Precertification Lookup from our Quick Tools menu. Requirements listed are for network providers. In many cases, out-of-network providers may be required to request precertification for services when network providers do not. Behavioral Health/Substance Abuse HealthPlus, an Amerigroup Company, offers behavioral health benefits for the following groups: n Medicaid is state-sponsored health insurance that assists those who are unable to afford medical care. n Child Health Plus is a New York state-sponsored, no- or low-cost health insurance program available to members of low-income families ages 0-19 who are not eligible for Medicaid and do not have other health insurance. n Health and Recovery Plan (HARP) is an enhanced benefit for Medicaid members with complex behavioral health needs. It is comprised of physical health, behavioral health, pharmacy and waiver services. HARP is for adults who have certain health conditions criteria as established by the State Department of Health. HARP helps members get the care they need while keeping them in their homes and communities. n Fully Integrated Duals Advantage Plan (FIDA) is an integrated care plan for the dual-eligible individuals who are eligible for both Medicare and Medicaid. By consolidating the benefits for all covered services into a single plan, the member has the ability to remain safely in his or her home and community and improve continuity of care across all acute care, long-term care, behavioral health, and home and community-based services using a patient-centered approach. Please follow the link below for a benefit quick reference guide. https://providers.amerigroup.com/providerdocuments/ NYNY_HP_BehavioralHealthQuickReference.pdf Services Medically supervised outpatient withdrawal Ambulatory Detox (OASAS services) Outpatient SUD services (OASAS BH solo/group practice) Opioid treatment program Methadone Maintenance (OTP) services (OASAS services) Outpatient services MH (OMH services BH solo/group practice) Comprehensive psychiatric emergency program Crisis Services including mobile crisis Inpatient hospital detoxification (OASAS service) Inpatient medically supervised inpatient detoxification (OASAS service) Inpatient treatment SA Rehab (OASAS service) Authorization needed No No No No (hospital needs to bill as CPEP) No (Notify plan within 24 hours of rendering the service) Benefit limit Should you have further questions, please contact our Provider Services toll free at
3 Services Authorization needed Benefit limit Inpatient psychiatric services (OMH service) Continuing day treatment Partial hospitalization PROS ACT Intensive case management/ supportive case management Health Home Care Coordination and Management Rehabilitation services for residential SUD treatment supports (OASAS service) Rehabilitation services for residents of community residences (year 2) Rehabilitation (COVERED FOR HARP) n Psychosocial Rehabilitation n Community Psychiatric Support and Treatment (CPST) Peer Supports (COVERED FOR HARP) Habilitation (COVERED FOR HARP) n Habilitation n Residential Supports in Community Settings Respite (COVERED FOR HARP) n Short-term Crisis Respite n Intensive Crisis Respite Nonmedical transportation (COVERED FOR HARP) Family Support and Training (COVERED FOR HARP) Employment Supports (COVERED FOR HARP) n Pre-vocational n Transitional Employment n Intensive Supported Employment n On-going Supported Employment Education Support Services (COVERED FOR HARP) Supports for self-directed care [phased in as a pilot; see details below] (COVERED FOR HARP) n Information and Assistance in Support of Participation Direction n Financial Management Services Now under HH No auths HH assignment and monitoring of care plan Now under HH No auths HH assignment and monitoring of care plan 500 Hours CY psychosocial rehab and CPST combined 500 Hours CY 250 Hours (habilitation and residential support) combined CY Short term 1 week per episode; 45 days per CY short and intensive crisis combined $2000/ per CY not applicable to members receiving residential services 30 Hours per CY Pre Voc; trans and supported 250 hours or 9 months max per CY 250 Hours per CY
4 Point-of-Care Blood Lead Testing Covered for children age 6 and younger and pregnant women. Physician office laboratories and limited service laboratories must bill for in-office testing dates using CPT-4 procedure code Cardiac Rehabilitation Precertification is required. Chemotherapy n Precertification is required for inpatient chemotherapy services. n No precertification is required for chemotherapy procedures* when performed in outpatient settings by a participating facility, provider office, outpatient hospital or ambulatory surgery center. *For information on coverage and precertification requirements for chemotherapy drugs, please see the Pharmacy section. Chiropractic Services Chiropractic care is not a covered service for adults. This is a covered benefit under the FFS Medicaid program for children younger than 21 as part of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program and only when ordered by a physician. Clinical Trials n Medicaid Managed Care members: Experimental treatment is covered on a case-by-case basis. n Child Health Plus (CHPlus) members: This is not a covered benefit. Precertification is required. Court-ordered Services Precertification is required for coverage of all services. Dental Services n Members may self-refer for dental checkups and cleaning exams. Dental benefits are administered through Healthplex, a network vendor. Dental procedures requiring anesthesia, planned inpatient admission or services at an outpatient ambulatory center must first be approved by Healthplex for the dental procedure. If approved, Healthplex will notify us, and a precertification request for anesthesia services will be completed. For temporomandibular joint (TMJ) services, see the Plastic/Cosmetic/Reconstructive Surgery section. n Medicaid Managed Care members: Members may self-refer to Article 28 clinics not in our network operated by academic dental centers to obtain covered dental services. Orthodontic care is covered. See the Orthodontic Care section. n CHPlus members: All necessary procedures requiring dental anesthesia for simple extractions and other routine dental surgeries that do not require hospitalization are covered and include in-office conscious sedation. Dermatology Services n No precertification is required for a network provider for Evaluation and Management (E&M) testing and procedures. n Services considered cosmetic in nature or related to previous cosmetic procedures are not covered. See the Diagnostic Testing section. Diagnostic Testing n No precertification is required for routine diagnostic testing. n Precertification is required for video electroencephalography (EEG). n Precertification from National Imaging Associates (NIA) is required for coverage of MRAs, MRIs, CAT scans, nuclear cardiac tests and PET scans. Call NIA at Durable Medical Equipment For the definition of Durable Medical Equipment (DME), please see your provider manual. n No precertification is required for glucometers, nebulizers, dialysis and end-stage renal disease equipment, gradient pressure aids, infant photo/light therapy, sphygmomanometers, walkers, orthotics for arch support, heels, lifts, or shoe inserts or wedges issued by a network provider. n Precertification is required for certain DME, including all DME billed with an RR modifier (rental) and DME items costing more than $1,500. n Precertification may be requested by completing a Certificate of Medical Necessity (CMN) available on our website or by submitting a physician order, a Precertification Request form and an itemized invoice. A properly completed and physician-signed CMN must accompany each claim for the following services: hospital beds, support surfaces, motorized and manual wheelchairs, continuous positive airway pressure machines, lymphedema pumps, osteogenesis stimulators, transcutaneous electrical nerve stimulators, seat lift mechanisms, power-operated vehicles, external infusion pumps, parenteral and enteral nutrition, and oxygen. n Enteral formula requires precertification, and is provided through DME as a medical benefit rather than a pharmacy benefit; precertification must be obtained through a DME vendor. Enteral formula and nutritional supplements are covered for: n Children who have metabolic or absorption disorders n Individuals who have rare, inborn metabolic disorders n Tube-fed individuals who cannot chew or swallow n Compression stockings: Specific gradient compression stockings are covered when prescribed as treatment of open venous ulcers and for pregnant members. n Certain items are considered comfort items and are not covered. For code-specific precertification requirements for DME, please visit our website. See the Disposable Medical Supplies section for guidelines relating to disposable medical supplies.
5 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Visit Members may self-refer for these services. Use the EPSDT schedule and document visits. Vaccine serum is received under the Vaccines for Children program. n Medicaid Managed Care members: Chiropractic services are covered for children younger than age 21 as part of the EPSDT program only when ordered by a physician. n CHPlus members: Health-care-covered services are covered according to the medical need and visitation schedules established by the American Academy of Pediatrics. Preventive services are not covered under EPSDT. Educational Consultation No notification or precertification is required. Emergency Services n No notification is required for emergency care given in the emergency room. n If emergency care results in admission, notification is required within 24 hours or the next business day. For observation precertification requirements, see the Observation section. Enteral Formula n Precertification is required. n Enteral formula and nutritional supplements are covered under the DME benefit and must be obtained through a DME provider rather than a pharmacy. n Medicaid Managed Care members: Covered for tube-fed individuals who cannot chew or swallow food; those with rare inborn metabolic disorders requiring specific medical formulas to provide essential nutrients not available through other means; and children who require medical formulas due to mitigating factors in growth and development. n CHPlus members: Coverage is based on medical necessity for the treatment of specific diseases: $2,500 per calendar year for modified solid food products containing low or modified protein used to treat inherited diseases of amino acid and organic acid metabolism. Family Planning/Sexually Transmitted Disease Care n Medicaid Managed Care members: May self-refer to an in-network or out-of-network provider. n Covered services include pelvic and breast examinations, lab work, drugs, genetic counseling, and devices and supplies related to family planning (e.g., intrauterine devices). n Infertility services and treatment are not covered. Gastroenterology Services n Precertification is required for upper endoscopy; bariatric surgery, including insertion, removal and/or replacement of adjustable gastric restrictive devices; and subcutaneous port components. n No precertification is required for a network provider for E&M, testing and some procedures. See the Diagnostic Testing section. Gynecology n Members may self-refer to a network provider. n No precertification is required for E&M, testing and procedures. Hearing Aids n Precertification is required for digital hearing aids. n Medicaid Managed Care members: Hearing aids, including replacements and repairs, are covered. Hearing aid batteries are covered. n CHPlus members: Hearing aids, including batteries and repairs, are covered. Hearing Screening n Simple hearing exams require PCP referral only. n No notification or precertification is required for coverage of diagnostic and screening tests, hearing aid evaluations, or counseling. n CHPlus members: One hearing examination per calendar year is covered. If an auditory deficiency requires additional hearing exams and follow-up exams, these exams will be covered. Home-Delivered Meals n This is only covered for MLTC members. Home Health Care n Precertification is required for all services. n Covered services include skilled nursing, home health aides, physical therapy (PT), occupational therapy (OT), speech therapy (ST), social work services and telehealth services when provided by agencies approved by the New York State Department of Health (NYS DOH). n CHPlus members: Home care services are limited to 40 visits per year for all types of service combined. Private duty nursing is not a covered benefit. Hospital Admission n Elective admissions require precertification. n Emergency admissions require notification within 24 hours or by the next business day. n To be covered, preadmission testing must be performed by one of our preferred lab vendors. See the provider referral directory for a complete listing of participating vendors. n No coverage for rest cures, personal comfort and convenience items, and services and supplies not directly related to the care of the patient, such as telephone charges, take-home supplies and similar costs.
6 Laboratory Services (Outpatient) n All laboratory services furnished by non-network providers require precertification except for hospital laboratory services in the event of an emergency medical condition. n For offices with limited or no office laboratory facilities, lab tests may be referred to one of our preferred lab vendors. See the provider referral directory for a complete listing of participating vendors. Medical Supplies For definitions of consumable and disposable medical supplies, please see your provider manual. n Medicaid Managed Care members: Medical supplies are covered and billable under medical benefits similar to DME. There are some medical supplies such as insulin syringes that are covered under pharmacy; for code-specific coverage information, please visit our website. n CHPlus members: Medical supplies are not covered with the exception of diabetic supplies and medical supplies routinely furnished as part of a clinic or office visit covered by HealthPlus Amerigroup. Medical supplies used during home care services are covered as part of the home care service rate. A list of these supplies can be found in the Medicaid Management Information Systems (MMIS) home health services provider manual. Neurology n No precertification is required for a network provider for E&M, testing and most procedures. n Precertification is required for neurosurgery, spinal fusion and artificial intervertebral disc surgery. See the Diagnostic Testing section. Observation Observation services are covered for patients who are seen, evaluated and admitted to an observation unit. Obstetrical Care No precertification is required for coverage of obstetrical (OB) services, including OB visits, diagnostic tests and laboratory services when performed by a participating provider. n Notification is required at the first prenatal visit. n No precertification is required for coverage of labor, delivery and circumcision for newborns up to 12 weeks of age. n Notification of delivery with newborn information is required within 24 hours. OB case management programs are available. See the Diagnostic Testing section. n No precertification is required for sonograms. One sonogram is covered per pregnancy; additional sonograms are covered with submission of supportive applicable diagnosis codes. Ophthalmology n No precertification is required for E&M, testing and procedures. n Precertification is required for repair of eyelid defects. Services considered cosmetic in nature are not covered. See the Diagnostic Testing section. See the Vision Services section. Oral Maxillofacial Precertification is required. See the Plastic/Cosmetic/ Reconstructive Surgery section. Orthodontic Care n Precertification is required. n Medicaid Managed Care members: Covered for children up to age 21 who have severe problems with teeth such as severely crooked teeth, cleft palate or cleft lip that causes difficulty chewing foods. Providers should call Healthplex at n Services are not covered for CHPlus members. Orthotics and Prosthetics For definitions of orthotics and prosthetics, please see your provider manual. n Precertification is required for certain orthotic devices. For code-specific precertification requirements for DME, please go to our website. n Precertification is not required for orthotics for arch support, heels, lifts, and shoe inserts and wedges when issued by a network provider. n Medicaid Managed Care members: Orthotics and prosthetics are covered according to New York State Medicaid criteria. See the Prescription Footwear section for details. n CHPlus members: Orthotics devices prescribed solely for use during sports and cranial prosthetics (e.g., wigs) are not covered. Dental prosthetics are covered only in treatment of congenital abnormalities, as part of reconstructive surgery, or if made necessary due to accidental injury to sound, natural teeth and if provided within 12 months of the accident. Otolaryngology (ENT) Services n No precertification is required for a network provider for E&M, testing and procedures. n Precertification is required for tonsillectomies and/or adenoidectomies, nasal/sinus surgery, and cochlear implant surgery and services. See the Diagnostic Testing section.
7 Out-of-Area/Out-of-Network Care Precertification is required except in cases of emergency care (including self-referral) and OB delivery. n Out-of-area care is only covered for emergent services; elective services are not covered. n Out-of-network care is only covered in instances of continuity of care for new enrollees, in which the provider leaves the network or if an in-network provider is not available to perform the service. n CHPlus members: This is not a covered benefit except for emergency services. Outpatient/Ambulatory Procedure/Surgery n Precertification requirement is based on the service performed. Visit our website for requirements. n Medicaid Managed Care members: Not covered for knee arthroscopy when the primary diagnosis is osteoarthritis of the knee (without mechanical derangement of the knee). Pain Management n Precertification is required for coverage of all services and procedures. n Medicaid Managed Care members: Not covered for prolotherapy, intradiscal steroid injections, facet joint steroid injections, systemic corticosteroids and traction (continuous or intermittent) for lower back pain. Personal Care Services (PCS) n Precertification is required for PCS. n PCS Level I (up to eight hours per week) and Level II are covered. Personal Emergency Response System (PERS) n Precertification is required for PERS and is based on a physician or nurse practitioner s order and a comprehensive assessment, which must include an evaluation of the member s physical disability status, the degree he or she would be at risk of an emergency due to medical or functional impairments or disability, and the degree of his or her social isolation. n Assessment for PERS services must be made in coordination with authorization procedures for home care services, including PCS. Pharmacy Medicaid Managed Care and CHPlus members receive pharmacy benefits through HealthPlus Amerigroup. The pharmacy benefit covers medically necessary prescriptions and over-the-counter (OTC) medications prescribed by licensed providers. Exceptions and restrictions exist as the benefit is provided under a closed formulary/preferred Drug List (PDL). Please refer to the appropriate PDL and/or the Medicaid Medication Formulary on our provider self-service website healthplus.amerigroup.com for the preferred products within therapeutic categories, as well as requirements for generics, step therapy, quantity edits and the PA process. Legacy Empire CHIP members are under a different PDL and/or Medicaid medication formulary from other HealthPlus Amerigroup members. Be sure to check the back of the member s ID card for applicable pharmacy information. Both PDLs and formularies are housed on our provider self-service website. n Prescription and OTC drugs are covered for Medicaid Managed Care and CHPlus members. Enteral formula is covered under the DME benefit. See the DME section. PA is required for all nonformulary drugs and other certain medications. n Medicaid Managed Care and CHPlus members: Growth hormone injections solely for Idiopathic Short Stature (ISS) in children are not covered. n Medical Injectable Drugs: Many self-injectable medications, self-administered oral specialty medications and officeadministered specialty medications are available through Accredo Specialty Pharmacy (depending on whether the member is a legacy HealthPlus Amerigroup or legacy Empire CHPlus enrollee) and require PA. To determine if a medical injectable requires precertification, please go to the Quick Tools section of our website and click on Precertification Lookup. For a complete list of covered injectables, please visit the Pharmacy section of our website. Important Phone Numbers for Pharmacy Prior Authorization If you need to... Call... Initiate a PA request for: n All legacy HealthPlus Amerigroup members and Empire CHPlus members n Medical injectables covered under the medical benefit for all members (legacy Empire and legacy HealthPlus Amerigroup) Schedule delivery once you receive a PA approval notice for legacy HealthPlus Amerigroup members Schedule delivery once you receive a PA approval notice for legacy Empire CHPlus members HealthPlus Amerigroup Pharmacy Help Desk: Express Scripts, Inc.: Accredo: Physiatry Precertification is required for coverage of all services and procedures related to pain management. See Behavioral Health section. Physical Medicine and Rehabilitation Precertification is required for coverage of all services and procedures related to pain management. Inpatient rehabilitation requires precertification.
8 Plastic/Cosmetic/Reconstructive Surgery (including Oral Maxillofacial Services) n No precertification is required for coverage of E&M codes. n All other services require precertification for coverage. n Services considered cosmetic in nature or related to previous cosmetic procedures (e.g., scar revision, keloid removal resulting from pierced ears) are not covered. n Reduction mammoplasty requires a HealthPlus Amerigroup medical director s review. n No precertification is required for coverage of oral maxillofacial E&M services. n Precertification is required for coverage of trauma to the teeth and oral maxillofacial medical and surgical conditions, including TMJ disorder. Podiatry n No precertification is required for E&M, testing and procedures when provided by a participating podiatrist. n Precertification requirement is based on the service performed. n Visit our website for requirements. n Medicaid members: Services provided by a podiatrist for persons younger than age 21 and adults with diabetes must be covered upon referral of a physician, registered physician assistant, certified nurse practitioner or licensed midwife. Prescription Footwear Prescription footwear is covered for the following: n Orthopedic footwear required by children under 21 n Shoes attached to a lower-limb orthotic brace n Footwear that is a component of a comprehensive diabetic treatment plan to treat amputation, ulcerations, preulcerative calluses, peripheral neuropathy with evidence of callus formation, foot deformities or poor circulation Radiation Therapy No precertification is required for coverage of radiation therapy procedures when performed by a participating facility or provider in the following outpatient settings: offices, outpatient hospitals and ambulatory surgery centers. Radiology Services See the Diagnostic Testing section. Rehabilitation Therapy (Short-Term): Occupational Therapy, Physical Therapy and Speech Therapy n No precertification is required for evaluation or coverage of outpatient therapy visits. n Children requiring therapy services to improve their ability to learn or participate in a school setting should be evaluated for school-based therapy. Other therapy services for rehabilitative care will be covered as medically necessary. n Medicaid members: Outpatient visits for physical, speech and occupational therapy are limited to 20 visits per service type per calendar year. Limitations do not apply for children younger than age 21, and individuals with developmental disabilities and traumatic brain injuries. n CHPlus members: Services are covered based on medical necessity. School-based Services n CHPlus members: School-based services are covered within network. n Medicaid members: This is not a covered benefit. Skilled Nursing Facility Precertification is required. Sleep Study Precertification is required.... Smoking Cessation Counseling No precertification or notification is required. Smoking cessation counseling must be provided by a physician, registered physician s assistant, registered nurse practitioner or licensed midwife during a medical visit. Group sessions are excluded. n Medicaid members: All eligible members are allowed up to six counseling sessions within a continuous 12-month period. Use diagnosis codes and Specialty Referral A referral is required for all specialty visits. The referral should be obtained from the member s PCP. There is no specific HealthPlus Amerigroup referral form. Referrals can be given on prescription or stationery. n No precertification is required for an in-network referral. n All out-of-network nonemergent services require precertification.... Sterilization Sterilization services are a covered benefit for members age 21 and older. n No precertification or notification is required for sterilization procedures, including tubal ligation and vasectomy. n A Sterilization Consent form is required for claims submission. For hysterectomies, use Form For sterilizations, use Form n Reversal of sterilization is not a covered benefit....
9 Transportation (Nonemergent) n No precertification or notification is required except for coverage of planned air transportation (airplane). n All nonemergency and routine transportation for members in New York is coordinated through LogistiCare Solutions, LLC. See the grid under Our Service Partners for LogistiCare phone and fax numbers by product and area: n Medicaid Managed Care: For members in the five boroughs, the state covers transportation services. For members in Nassau County, we cover transportation services. n CHPlus members: This is not a covered benefit.... Urgent Care Center No notification or precertification is required for a participating or nonparticipating facility. Vision Services Vision services are administered through Superior Vision (formerly Block Vision). Members may contact Superior Vision at Providers may contact Superior Vision at n Medicaid Managed Care: Members are allowed to self-refer to any participating vision services provider (optometrist or ophthalmologist) for refractive vision services once every two years* unless eyeglasses are lost, damaged or destroyed. Eyeglasses and examinations are limited to once every 24 months.* Contact lenses are covered once every 24 months only when medically necessary. Members who are diagnosed with diabetes are eligible for an annual dilated eye (retinal) examination. n CHPlus members: Vision examinations performed by a physician or optometrist for the purpose of determining the need for corrective lenses and, if needed, to provide a prescription, are covered. Vision examinations and eyeglasses are covered every 12-month period. Please note: Members are financially responsible for upgrades of frames and/or lenses not medically necessary (e.g., personal preference upgrades). *Unless justified as medically necessary.... Well-Woman Exam Members may self-refer for these services. Well-woman exams are covered twice per calendar year when performed by a PCP or an in-network GYN. Exam includes routine lab work, STD screening, Pap smear and mammogram (for ages 35 and older).... Revenue Codes Precertification or notification is required for services billed by facilities with revenue codes for: n Inpatient n OB n Home health care n Hospice n MRI n High-dollar injectables n Chemotherapeutic agents n Pain management n Rehabilitation (physical/ occupational/respiratory therapy) n Short-term rehabilitation (speech therapy) For a list of the specific revenue codes requiring precertification, please visit our website. healthplus.amerigroup.com
10 Administrative, Provider, Health and Claims Services Medical Appeals n Our Service Partners Express Scripts (Pharmacy Benefits Manager [PBM] for HealthPlus Amerigroup and Empire CHPlus members) Pharmacy Help Desk:* *Submit all PA requests to HealthPlus Amerigroup. Accredo Specialty Pharmacy (specialty pharmacy for MMC and legacy HealthPlus Amerigroup CHPlus members) Call after receiving prior authorization. Accredo (specialty pharmacy for legacy Empire CHPlus members) LogistiCare (transportation services) Call to schedule delivery. Phone: n All MLTC members: n Nassau County MMC and CHP members, all counties: n MMC members in the five boroughs: Fax: n Hospital discharge: n All MLTC and Nassau Co. MMC members: n MMC members in: n Brooklyn: n Queens: n Manhattan: n Bronx: n Staten Island: Website: Superior Vision (vision services) Healthplex (dental services) Member line: Provider line: Call and select: n Prompt 2 for the Emergency Referral Unit n Prompt 3 for Provider Services n Prompt 4 for Provider Relations HearUSA (hearing services) National Imaging Associates, Inc. (radiology precertification) ( for TDD relay services);
11 Administrative, Provider, Health and Claims Services Medical Appeals n Provider Experience Program Our Provider Services team offers precertification, case and disease management, automated member eligibility, claims status, health education materials, outreach services, and more. Call Monday through Friday from 8 a.m. to 6 p.m. Eastern time. Provider Website and IVR Available 24/7/365: To verify eligibility, check claims and referral authorization status, and look up precertification/notification requirements, visit healthplus.amerigroup.com. Can t access the Internet? Call Provider Services and simply say your national provider ID when prompted by the recorded voice. The recording guides you through our menu of options just select the information or materials you need when you hear it. n Claims Services Timely filing is within 90 days from the date of service. n Electronic Data Interchange Call to get started. We accept claims electronically through three clearinghouses: Emdeon, Availity and Capario. Use payer number for Emdeon, for Availity and for Capario. n Paper Claims Please submit claims on original claim forms (CMS-1500 or CMS-1450) with dropout red ink, printed or typed (not handwritten) in large, dark font. Mail paper claims to the following address: New York Claims HealthPlus, an Amerigroup Company P.O. Box Virginia Beach, VA Please note: AMA- and CMS-approved modifiers must be used appropriately based on the type of service and procedure code. n Payment Disputes Claim payment disputes must be filed within 45 calendar days of the adjudication date of the explanation of payment. Forms for provider appeals are located on our website and should be sent to: Payment Disputes HealthPlus, an Amerigroup Company P.O. Box Virginia Beach, VA For Medicare precertification and notification guidelines, visit the Medicare section of our website. n Medical Appeals Medical appeals (also known as medical administrative reviews) can be initiated by the member or the provider on behalf of the member and must be submitted within 60 business days from the date of the notice of proposed action. Medical appeals can be submitted in writing to: Medical Appeals HealthPlus, an Amerigroup Company P.O. Box Virginia Beach, VA A provider submitting on behalf of a member can write a letter or use the Provider Appeals form located on our website. n Health Services Case Management Services We offer a case management program that provides education and support to help the member make informed health care choices. Our goal is to help the member get the care they need, when they need it. A team of licensed nurses and social workers assist the member by providing education about health conditions and assisting with provider appointments. This includes identifying community resources, providing health education, monitoring compliance, assisting with transportation, etc. Disease Management Centralized Care Unit (DMCCU) Services We offer DMCCU services to members with the following medical conditions: asthma, bipolar disorder, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, HIV/ AIDS, hypertension, obesity, major depressive disorder, schizophrenia and transplant. DMCCU services include educational information like local community support agencies and events in the health plan s service area. 24/7/365 Nurse HelpLine Members may call our 24-hour Nurse HelpLine for nursing advice 7 days a week, 365 days a year. When a member uses this service, a report is faxed to your office within 24 hours of receipt of the call.