Características generales y organolépticas de la madera

Precertification is required and applies to the following types of care. This list may be modified periodically:

 Home health care

 Hospice programs (notification only for outpatient hospice services)

 Skilled nursing or extended care facilities

 Physical and speech therapy beyond the initial evaluation (subsequent visits require clinical documentation and precertification from Amerigroup)

 DME

 Cardiac rehabilitation

 Telephonic pacemaker check

 Outpatient diagnostic radiology at some Maryland hospitals

In addition, precertification is required for all out-of-network care (certain exclusions apply) and for specialty visits (i.e., services beyond the initial evaluation and management) if performed by a nonparticipating provider.

For code-specific precertification requirements for dermatology, genetics, otolaryngology, podiatry, plastic surgery and pain management performed in a participating clinic/outpatient facility/ambulatory surgery center, please refer to providers.amerigroup.com/MD and click on the Precertification Lookup tool.

For certification requirements for substance abuse services, please refer to the ValueOptions website at www.valueoptions.com or the DHMH website at

http://dhmh.maryland.gov/ohcq/SA/default.aspx. Ambulatory Surgery Precertification

We are committed to providing quality, accessible health care in the most efficient manner. In most cases, certain outpatient services can be safely performed in a freestanding facility rather than a hospital outpatient setting. Therefore, certain types of outpatient surgery/services will require site-of-service precertification if hospital outpatient is requested. Services that cannot be safely and effectively provided at a freestanding site will be precertified at hospitals in these areas. These ambulatory surgical procedures must receive coverage approval through the Medical Management department at least 72 hours prior to the scheduled procedure.

For code-specific precertification requirements for these services when performed in a participating clinic/outpatient facility/ambulatory surgery center, refer to the Precertification Lookup tool on our provider self-service website.

Precertification Requirement Review and Updates

We review and revise our policies when necessary. The most current policies are available on our provider self-service website.

Specialist as PCP Referral

Under certain circumstances, a specialist may be approved by Amerigroup to serve as a member’s PCP when a member requires the regular care of the specialist. The criteria for a specialist to serve as a member’s PCP include the existence of a chronic, life-threatening illness or condition of such complexity whereby:

 The need for multiple hospitalizations exists

 The majority of care must be provided by a specialist

 The administrative requirements of arranging for care exceed the capacity of the PCP. This would include members with complex neurological disabilities, chronic pulmonary disorders, HIV/AIDS, complex hematology/oncology conditions, cystic fibrosis, etc.

The specialist must meet the requirements for PCP participation (including contractual obligations and credentialing), provide access to care 24 hours a day, 7 days a week and coordinate the member’s health care, including preventive care. When such a need is identified, the member or specialist must contact the Amerigroup Case Management department and complete a Specialist as PCP Request Form. An Amerigroup case manager will review the request and submit it to the Amerigroup medical director. Amerigroup will notify the member and the provider of our determination in writing within 30 days of receiving the request. Should Amerigroup deny the request, we will provide written notification to the member and provider of the reason(s) for the denial of the request. Specialists serving as PCPs will continue to be paid under fee-for-service while serving as the member’s PCP. The designation cannot be retroactive. For further information, see the Specialist as PCP Request Form in the Appendix A – Forms section of the manual.

Reporting Changes in Address and/or Practice Status Please report any status changes using the methods below:

Fax to: 1-866-920-1873

Mail to: Provider Services

Amerigroup Community Care 7550 Teague Road, Suite 500

Hanover, MD 21076 Second Opinions

A member or the member’s PCP may request a second opinion for serious medical conditions or elective surgical procedures at no cost to the member. Also, a member of the health care

team and/or the member’s parents or guardians may also request a second opinion. These conditions and/or procedures include but are not limited to the following:

 Treatment of serious medical conditions such as cancer

 Elective surgical procedures such as hernia repair (simple) for adults (age 18 or older), hysterectomy (elective procedure), spinal fusion (except for children under age 18 with a diagnosis of scoliosis) and laminectomy (except for children under age 18 with a diagnosis of scoliosis)

 Other medically necessary conditions as circumstances dictate

The second opinion must be obtained from a network provider (see the provider referral directory at providers.amerigroup.com/MD) A second opinion can be obtained from a non- network provider if there is not a network provider with the expertise required for the condition. Once approved, the PCP will notify the member of the date and time of the appointment and will forward copies of all relevant records to the consulting provider. The PCP will notify the member of the outcome of the second opinion.

Amerigroup may also request a second opinion at its own discretion. This includes but is not limited to the following scenarios:

 There is concern about care expressed by the member or the provider

 Potential risks or outcomes of recommended or requested care are discovered by the plan

during its regular course of business

 Before initiating denial of coverage of service

 Denied coverage is appealed

 An experimental or investigational service is requested

When Amerigroup requests a second opinion, we will make the necessary arrangements for the appointment, payment and reporting. Once the second opinion is completed, Amerigroup will inform the member and the PCP of the results and the consulting provider’s conclusion and recommendation(s) regarding further action.