Amerigroup Iowa, Inc. will begin using the Provider Data Management (PDM) application on Availity Essentials* to verify and initiate care provider demographic change requests for all professional and facility care providers.**  There is no cost for your providers to register or to use any of our digital applications on Availity Essentials.

Going forward, Availity PDM is now the intake application for care providers to submit demographic change requests, including submitting roster uploads. Availity PDM will replace all current intake channels for demographic change requests and roster submissions as of October 1, 2023. 

If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups.

Take action now

Don’t wait until October to start using the PDM application. Start using it today to take advantage of the benefits of this application and familiarize yourself with the process before the legacy intake channels retire. 

What features does the Availity PDM application provide?

It allows you to:

• Update provider demographic information for all assigned payers in one location.
• Attest and manage current provider demographic information.
• Review the history of previously verified data.

Benefits to our care providers using Availity PDM

The Availity PDM application will ensure the following:

• Consistently updated data
• Decreased turnaround time for updates 
• Compliance with federal and/or state mandates
• Improved data quality through standardization
• Increased provider directory accuracy
• Choice and flexibility to request data updates via the standard PDM experience or by submitting a spreadsheet via a roster upload

Want to submit a roster using Availity PDM?

Don’t wait — Start submitting today. Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:***

1. Utilize the Roster Automation Standard Template:
   • For your convenience, there is a standard roster Excel document. Find it online here.
2. Follow the Roster Automation Rules of Engagement:
   • A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). Find it online here.
3. Upload your completed roster via the Availity PDM application.
4. Join our live webinar:
   • Title of webinar: Roster Automation Template and Rules of Engagement Training
   • Date: Monday, August 21, 2023
   • Time: 4 to 5 p.m. ET
   • Registration link: here

What about the previous methods by which I have been submitting information?

While we are in the process of sunsetting our legacy intake channels, we will continue to process submissions received through current intake channels until September 30, 2023. Effective October 1, 2023, all PDM requests, including rosters, must be submitted via Availity PDM. As of this date, all provider demographic change requests, including rosters, will be rejected if submitted through any format/channel other than Availity PDM. Again, if preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups.

How to access the Availity PDM application

Log onto Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts.  

Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

Training is available:

• Learn about and attend one of our training opportunities by visiting here.
• View the Availity PDM quick start guide here.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by logging into Availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page. 

If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY.

Note: For national providers who provide services in multiple markets, California (all lines of business), Colorado (Commercial and Medicare), and Nevada (all lines of business) are not available for Availity PDM until our Strategic Provider System migration.  

** Exclusions:

• Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health. 
• Any specific state mandates or requirements for provider demographic updates.

*** If any roster data updates require credentialing, your submission will be routed appropriately for further action.

Background:

We continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. Provider performance can vary widely in relation to efficiency, quality, and member experience. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables.

Beginning January 1, 2023, we added a new sorting option on the FindCare tool for members to leverage when they are searching for a primary care provider. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers are listed in order of their total score, though no individual scores appear within the tool or be visible to Medicare covered patients. The Personalized Match Phase 1 algorithm is based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options are still available on FindCare for our members.

Personalized Match Phase 1 highlights:

• We strive to make healthcare simpler, more affordable, and more accessible, and one of the ways to help achieve that goal is to ensure that consumers are connected with care providers who have strong track records delivering quality care.
• Beginning on November 10, 2023, we will upgrade the online FindCare tool for Medicare members with a new sorting option called Personalized Match Phase 1, to match consumers with providers who perform well in efficiency and quality metrics within a certain geographical distance.
• The new sorting option, known as Personalized Match Phase 1, will be the default for consumers who search for Medicare non-primary specialty care providers in FindCare.
• We currently offer Personalized Match to Commercial consumer members. Personalized Match seeks to match consumers with documented health conditions with provider ranked based on cost effectively managing quality care. For example, if a consumer who has been given a diagnosis of diabetes conducts a search, they will be matched with providers whose patients are more likely to cost effectively manage similar patients with diabetes (for example, consistently receive recommended A1c tests A consumer who is a 60-year-old male would receive different Personalized Match provider rank order than a consumer who is a 30-year-old female). The goal is to move to this full Personalized Match solution in Medicare in the future. Personalized Match Phase 1 only analyzes providers’ quality and efficiency performance regardless of member characteristics for generating the sort order.
• You may review a copy of the new sorting methodology which has been posted on Availity.*
• If you have general questions regarding this new sorting option, please submit an inquiry via the web on Availity.
• If you would like information about your scoring used for this sorting option or if you would like to request reconsideration of your score, you may do so by submitting an inquiry via the web on Availity.
• This change is part of a greater effort to help improve access to high quality, affordable healthcare, which is essential to our customers.

FAQ

Why are we reimagining the strategy for evaluating non-primary specialty care providers?

There is variability in provider performance (efficiency, quality, experience), and we want to ensure all members receive high-quality care that leads to improved patient outcomes. The strategy aligns with the future direction of our specialty provider care strategy. This phase of the Medicare FindCare improvement utilizes measures related to appropriate practice (for example, overuse and underuse measures). We utilize a vendor, Motive Medical, to generate an overall Appropriate Practice Score at the NPI level, based on all CMS Fee-for-Service members.

How will I know my inquiry went through successfully once I submit?

An email will be sent to the inquirer acknowledging receipt of inquiry within two business days.

What is the turnaround time from when I submit my question to receiving an answer?

The goal is to have all questions answered within two business days. If further clarification is needed, or if detailed research is required, that time frame will be extended.

How will I receive my response?

An email will be sent with the required information back to the email address provided during the initial inquiry request.

How do I submit an inquiry?

Inquiries can be made at Availity site. There are three dropdown options for inquiry types. These are: 1) General Program Inquires, 2) Request a Copy of Your Provider Performance Scorecard, and 3) Provider Performance Scorecard Inquiries. An open text field is available to describe the nature of the inquiry in more detail.

What type of inquiries can I submit?

Any questions relating to Personalized Match Phase 1 that is not answered in this FAQ or by the Methodology document.

Do providers have any recourse if they feel their Provider Performance Scorecard is inaccurate?

If a provider disagrees with their Provider Performance Scorecard results, the provider can submit an inquiry at Availity site detailing their reasoning. We will determine the best course of action as needed, but potential outcomes could be a provider consultation, reanalysis, and potentially a rescoring of provider performance to be reflected in Personalized Match Phase 1 and the Provider Performance Scorecard.

What provider specialties are included in Personalized Match Phase 1?

For 2023, selected non-primary specialty care providers are included. We plan to potentially incorporate other provider specialties in future provider performance evaluations.

What measures are included in quality scoring and why were they included?

The quality measures selected for Personalized Match Phase 1 include underuse and overuse measures, within the appropriate practice domain. Measures vary by specialty and are available on request.

How are measures weighted?

Motive Medical considers three factors in weighting the importance of each measure as it impacts the overall NPI Appropriate Practice Score (APS):

• Measure volume (for example, the number of instances a provider is eligible for measurement)
• Cost differential (for example, the difference in cost between the inappropriate service chosen versus the cost of the appropriate alternative), and
• Patient harm (for example, measures weigh more heavily if they have a stronger negative impact on the patient).

What measurement year and source are used in quality scoring?

Motive Medical’s Fall 2022 Refresh was used for quality scoring with varying claim periods by measure including dates from January 1, 2019, to December 31, 2021.

What are the inclusion criteria for quality scoring?

A non-primary specialist care provider must have at least three appropriateness measures with at least ten members in each measure (a few measures require 20 members) for the APS score to be calculated. If the provider does not meet this threshold, the APS score is not available.

The APS score can be described in the following steps:

• Within each specialty, calculate the mean Motive Medical APS score to be used as the national-specialty benchmark.
• For each non-primary care specialty provider, calculate an APS Observed to Expected (O/E) ratio, comparing the provider to the benchmark for the same specialty:
  • Provider’s APS / national-specialty benchmark.
• The quality score is the provider’s APS O/E percentile ranking at the national-specialty level.

What factors go into your efficiency target?

The factors going into our efficiency target are the episodes of the members are assigned to provider specialty who has the highest cost within the episode for Surgery and Evaluation costs. The observed cost of an episode is the sum of provider’s total allowed costs. The expected or peer benchmark cost of an episode is the average cost of treating the same condition or procedure with the same severity level for all specialists in the same line of business, specialty and geographic area multiplied by number of provider’s volume. For ETGs the measure is at the condition level (diabetes, asthma) and for PEGs it’s the procedure level (knee replacement, lumbar fusions):

• Observed cost: Total provider cost
• Expected cost: Specialty average cost for same case mix * physician volume
• Efficiency index = observed / expected 

How is your efficiency target set?

Efficiency scores from the condition ETG and PEG procedure (observed/expected ratio scores) are blended into one final efficiency score by weighing the percentage of all the dollars that are tied to procedures vs conditions. This ensures that the efficiency scores for proceduralists (surgeons) are based more heavily on the procedure episodes. This is the final blended efficiency score for the provider:

• A minimum of 20 episodes that have benchmarks are required to calculate a condition efficiency or procedure efficiency score for the provider.
• A 90% statistical confidence interval is computed around the provider’s final blended efficiency score to account for the level of statistical uncertainty around the point estimation. For example, a provider with a final blended efficiency score of 0.97 might have the following confidence interval: Upper confidence level (UCL) of 1.03, Lower Confidence level (LCL) of 0.91.  

Cost ratings are then assigned to providers and provider groups using confidence intervals, as shown below. The provider group cost ratings are used for TIN Designation while individual provider cost ratings are used for the Provider composite score.

 For high-cost cases, how do you normalize which can occur across different groups?

We exclude outlier episodes from the scoring, low cost and high-cost episodes are flagged by the software at Condition/Procedure, Severity, and Line of business level.

Provider specialties with quality measures:

Find Care, the doctor finder and transparency tool in the Amerigroup online directory, provides Amerigroup members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetical order, and provider name.

Beginning in the second quarter of 2024 or later, an additional sorting option will be available for our Medicare Advantage members to search by provider performance called Personalized Match Phase 1. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Providers with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name:

• You may review a copy of the Personalized Match Phase 1 methodology that has been posted on Availity* – our secure Web-based provider tool – using the following navigation:   Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Phase 1 Methodology.pdf.
• If you have general questions regarding this new sorting option, please submit an inquiry via the web at Availity.  
• If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.  

Amerigroup has expanded the scope of Personalized Match Phase 1 to include selected specialty providers and will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.

Having reliable internet access is an important part of life. The internet helps us find information and connect with people, including finding and connecting with healthcare providers via virtual visits. However, not everyone can afford it. We share a health vision with our care provider partners that means real change for consumers. Making the internet more accessible is one way we can improve the whole health of our communities.

The Affordable Connectivity Program can help.

What is the Affordable Connectivity Program?

The Affordable Connectivity Program is a government program that helps families who may need assistance pay for internet access. Qualified households can receive:

• Up to a $30/month discount on internet service.
• Up to a $75/month discount on internet service if they live on certain Tribal lands.
• Up to a $100 one-time discount on a laptop, desktop, or tablet bought through a participating internet provider.

Who is eligible for the program?

A household is eligible for the Affordable Connectivity Program if:

• The household income is 200% or less than the Federal Poverty Guidelines.
• Someone in the household (including a child or dependent):

• Participates in certain government assistance programs such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, Social Security Income (SSI), the Free and Reduced-Price School Lunch Program or School Breakfast Program, or others.
• Participates in certain Tribal assistance programs, such as Head Start, Tribal Temporary Assistance for Needy Families (TANF), or others.
• Received a Federal Pell Grant during the current award year.
• Already receives a Lifeline benefit (another government program providing discounts on internet and phone service). 

How do my patients apply?

Your eligible patients can apply for the Affordable Connectivity Program online or by mail. They can also ask their current internet provider if they participate in the program. Please direct your patients to learn more at AffordableConnectivity.gov.

As we communicated in July, August, and September, the Provider Data Management (PDM) application on Availity Essentials* is now the only intake application to verify and initiate care provider demographic change requests, including submitting roster uploads, for all professional and facility care providers.** Previous intake channels are now retired as of October 1, 2023. 

If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups.

Training is available:

• PDM application specific trainings:
  • Learn about and attend one of our training opportunities by visiting here.
  • View the Availity PDM quick start guide here.

Note: An Availity account is required to access these training options. If not registered yet, see below for registration details.

• Roster Automation Standard Template and Roster Automation Rules of Engagement specific training:
  • Listen to our recorded webinar here.

Choice and flexibility to select the option that works best for you

Request data updates via either of the following options:

• Standard PDM experience
• Submitting a spreadsheet via a roster upload

Benefits to our care providers using Availity PDM

The Availity PDM application will ensure the following:

• Consistently updated data
• Decreased turnaround time for updates
• Compliance with federal and/or state mandates
• Improved data quality through standardization
• Increased provider directory accuracy

Want to submit a roster using Availity PDM?

Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation:***

1. Utilize the Roster Automation Standard Template:
   • For your convenience, there is a standard roster Excel document. Find it online here.
2. Follow the Roster Automation Rules of Engagement:
   • A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. Find it online here.
   • More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). 
3. Upload your completed roster via the Availity PDM application.

Availity PDM compatibility check for roster submissions

Availity PDM has been enhanced to incorporate a roster compatibility check. Providers can see if the roster was successfully submitted:

• If there is an error to the roster, providers will see an error rejection message with detailed reason for the rejection.
• Errors will need to be corrected. Then, the roster should be re-uploaded. Status will show as successfully submitted once corrected and re-submitted.
• After successful submission of the roster, all accepted elements of the roster will be processed and only errors/rejections will fall out.
• Any elements that fall out will require manual intervention.

How to access the Availity PDM application

Log onto Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts.

Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, please ensure you have registered all TINs associated with your Availity account.

If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY (282-4548).

** Exclusions:

• Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
• Any specific state mandates or requirements for provider demographic updates.

*** If any roster data updates require credentialing, your submission will be routed appropriately for further action.

Note: The following requested adds, changes, or terminations will be routed to the Provider Contracting team for validation and impact to provider contracts and network adequacy:

• Change tax ID
• Change organization name
• Add a network to agreement
• Change provider specialty
• Terminate entire agreement

This forum has moved from the original date of September 27, 2023 to October 19, 2023

Register today for the youth mental health forum hosted by Amerigroup Community Care and Motivo* for Amerigroup providers on October 19, 2023.

This important event will address the critical need to engage young people in leading their mental health. By deepening the discussion on youth mental health, we can do our part to foster a culture of understanding and support for youth and young adults. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve. 

Please join us to hear from a diverse panel of experienced professionals and young leaders as we explore the challenges experienced by today’s youth, amplify the experiences and ideas of young people, and equip attendees with practical tools and innovative approaches to create meaningful change.

Each forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address, and deconstruct bias, have difficult and productive conversations, learn about valuable resources, increase inclusion, advance equity in healthcare.

Thursday, October 19, 2023
3:30 to 5 p.m. Eastern time

Please register for this event by visiting this link.

Policy Update

Robotic Assisted Surgery 

(Policy G-10004, effective 01/01/2024) 

Beginning with dates of service on or after January 1, 2024 Robotic Assisted Surgery reimbursement policy for Amerigroup Iowa, Inc. will expand to include CPT^® codes for computer-assisted surgical systems.   

This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed. 

The Related Coding section of the policy has been updated to include the following computer assisted surgical musculoskeletal navigation procedures:

• 0054T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (list separately in addition to code for primary procedure)
• 0055T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (list separately in addition to code for primary procedure) 

The policy has been renamed to Technology Assisted Surgical Procedures which defines both robotic assisted and computer assisted techniques.  

New Reimbursement Policy 

Genetic Tests: Once per Lifetime
(Policy G-23002, effective 01/01/2024) 

Beginning with dates of service on or after January 1, 2024, Amerigroup will implement a new reimbursement policy titled Genetic Tests: Once per Lifetime. This policy identifies specific genetic tests allowed once in a member’s lifetime. During the member’s lifetime, the germline genotype will not change. However, the interpretation of the gene sequence may change due to recategorization of variants, or other factors. Repeat sequencing is not required for future interpretation of germline genotype, or re-analysis of previously sequenced data. 

The Related Coding section includes a Once per Lifetime Genetic Test coding list, which describes the genetic procedures that are limited to once per lifetime sequencing. Reinterpretation of the original results are not separately reimbursable. 

For additional information, please review the Genetic Tests: Once per Lifetime reimbursement policy at https://provider.amerigroup.com.

The previous effective date was previously listed in error as October 1, 2023, this correct effective date is December 1, 2023.

Effective for dates of service on and after December 1, 2023, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Effective for dates of service on and after January 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process. 

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.