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Real
Solutions
Florida Statewide Medicaid Managed Care
Managed Medical Assistance and Florida Healthy Kids
Provider Manual
Amerigroup Florida, Inc.
1-800-454-3730
n
providers.amerigroup.com/fl
Copyright July 2014 Amerigroup Corporation
Amerigroup Florida, Inc. is a wholly owned subsidiary of Amerigroup Corporation whose parent
company is WellPoint, Inc. (WellPoint). All rights reserved. This publication, or any part thereof, may
not be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, storage in an information retrieval system or otherwise, without the prior
written permission of Amerigroup Corporation, Communications Department, 4425 Corporation Lane,
Virginia Beach, Virginia 23462-3103, telephone 757-490-6900. The Amerigroup Corporation website is
located at www.amerigroup.com.
How to apply for participation
If you are interested in applying for participation with Amerigroup Community Care, please visit
providers.amerigroup.com or call a Provider Relations representative at 1-888-821-1108.
FL-PM-0024-14
Table of Contents
INTRODUCTION ............................................................................................................................................................... - 1 OVERVIEW ....................................................................................................................................................................... - 2 Who Is Amerigroup? ................................................................................................................................................................- 2 Mission .....................................................................................................................................................................................- 2 Strategy ....................................................................................................................................................................................- 2 Summary ..................................................................................................................................................................................- 2 QUICK REFERENCE INFORMATION ................................................................................................................................... - 3 Amerigroup Phone Numbers ...................................................................................................................................................- 3 Other Telephone Numbers ......................................................................................................................................................- 3 Amerigroup Website................................................................................................................................................................- 4 Provider Experience Program ..................................................................................................................................................- 4 Ongoing Provider Communications .........................................................................................................................................- 4 PRIMARY CARE PHYSICIANS ............................................................................................................................................ - 7 Primary Care Physicians ...........................................................................................................................................................- 7 Provider Specialties .................................................................................................................................................................- 7 Primary Care Physician Onsite Availability ..............................................................................................................................- 8 Provider Disenrollment Process...............................................................................................................................................- 8 Member Enrollment ................................................................................................................................................................- 9 Involuntary Disenrollment .......................................................................................................................................................- 9 Newborn Enrollment .............................................................................................................................................................- 10 Members Eligibility Listing .....................................................................................................................................................- 10 Member ID Cards ...................................................................................................................................................................- 11 Americans with Disabilities Act Requirements ......................................................................................................................- 11 Medically Necessary Services ................................................................................................................................................- 11 Continuity of Care ..................................................................................................................................................................- 12 AMERIGROUP HEALTH CARE BENEFITS AND COPAYMENTS ........................................................................................... - 13 Amerigroup Covered Services................................................................................................................................................- 13 Enhanced Benefits .................................................................................................................................................................- 13 Taking Care of Baby and Me Program ...................................................................................................................................- 16 Prenatal Program ............................................................................................................................................................- 16 Postpartum Program ......................................................................................................................................................- 16 Quality Enhancement Program..............................................................................................................................................- 16 Well-child Visits/Early and Periodic Screening, Diagnosis and Treatment (EPSDT) ...............................................................- 17 Well-child Visits Reminder Program ......................................................................................................................................- 18 Blood Lead Testing Requirements .........................................................................................................................................- 19 Vaccines for Children for Medicaid Recipients ......................................................................................................................- 19 Family Planning Services ........................................................................................................................................................- 20 Smoking Cessation Program ..................................................................................................................................................- 20 Resources and Tools .......................................................................................................................................................- 20 Online Resources ............................................................................................................................................................- 20 Online Continuing Education for Physicians ...................................................................................................................- 21 Printed Resources for Members .....................................................................................................................................- 21 Printed Resources for Providers .....................................................................................................................................- 21 Audiology Services .................................................................................................................................................................- 21 Outpatient Laboratory and Radiology Services .....................................................................................................................- 22 Pharmacy Services .................................................................................................................................................................- 22 Covered Drugs ................................................................................................................................................................- 22 Prior Authorization Drugs ...............................................................................................................................................- 22 Over-The-Counter Drugs ................................................................................................................................................- 22 Excluded Drugs ...............................................................................................................................................................- 24 -
Informed Consent for Psychotherapeutic Medications for Children..............................................................................- 24 Behavioral Health Services ....................................................................................................................................................- 24 Overview .........................................................................................................................................................................- 24 Primary and Specialty Services .......................................................................................................................................- 24 Referral for Mental Health and Alcohol and Drug Abuse Conditions .............................................................................- 25 Behavioral Health Claims ................................................................................................................................................- 25 Behavioral Health Emergency Services...........................................................................................................................- 25 Behavioral Health Medically Necessary Services............................................................................................................- 25 Behavioral Health Coordination of Care .........................................................................................................................- 26 Free Training and Certification Websites .......................................................................................................................- 26 Self-referral Services ..............................................................................................................................................................- 27 Member Rights and Responsibilities .....................................................................................................................................- 27 Patients’ Rights ...............................................................................................................................................................- 27 Patients’ Responsibilities ................................................................................................................................................- 28 First Line of Defense Against Fraud .......................................................................................................................................- 28 General Obligation to Prevent, Detect and Deter Fraud, Waste and Abuse ..................................................................- 28 Importance of Detecting, Deterring and Preventing Fraud, Waste and Abuse ..............................................................- 29 Provider Fraud, Waste and Abuse ..................................................................................................................................- 29 Member Fraud, Waste and Abuse ..................................................................................................................................- 30 HIPAA .....................................................................................................................................................................................- 30 MEMBER MANAGEMENT SUPPORT ............................................................................................................................... - 32 Welcome Call .........................................................................................................................................................................- 32 Appointment Scheduling .......................................................................................................................................................- 32 Nurse HelpLine.......................................................................................................................................................................- 32 Interpreter Services ...............................................................................................................................................................- 32 Health Promotion ..................................................................................................................................................................- 33 Case Management .................................................................................................................................................................- 33 Disease Management Centralized Care Unit .........................................................................................................................- 34 Program Features ...........................................................................................................................................................- 34 Who is Eligible? ...............................................................................................................................................................- 34 DMCCU Provider Rights and Responsibilities .................................................................................................................- 35 Hours of Operation .........................................................................................................................................................- 35 Contact Information .......................................................................................................................................................- 35 Health Education Advisory Committee ..................................................................................................................................- 35 WIC Program ..........................................................................................................................................................................- 36 WIC Referrals ..................................................................................................................................................................- 36 Pregnancy-related Requirements ..........................................................................................................................................- 36 Prenatal Risk Screening ..................................................................................................................................................- 36 Infant Risk Screening ......................................................................................................................................................- 37 HIV Testing ......................................................................................................................................................................- 37 Hepatitis B Screenings ....................................................................................................................................................- 37 Hepatitis B and Hepatitis B Immune Globulin Vaccines .................................................................................................- 38 Testing Positive for Hepatitis B .......................................................................................................................................- 38 Healthy Start Program ...........................................................................................................................................................- 40 Local Health Department .......................................................................................................................................................- 40 PROVIDER RESPONSIBILITIES ......................................................................................................................................... - 41 Medical Home ........................................................................................................................................................................- 41 Providers’ Bill of Rights ..........................................................................................................................................................- 41 Responsibilities of the PCP.....................................................................................................................................................- 42 Role of the PCP ...............................................................................................................................................................- 44 Physician Extenders ........................................................................................................................................................- 45 Background Checks ................................................................................................................................................................- 46 ABUSE, NEGLECT AND EXPLOITATION .........................................................................................................................................- 46 -
PCP Access and Availability ....................................................................................................................................................- 46 Member Missed Appointments .............................................................................................................................................- 47 Noncompliant Amerigroup Members ....................................................................................................................................- 48 PCP Transfers .........................................................................................................................................................................- 48 Covering Physicians ...............................................................................................................................................................- 48 Specialist as a PCP ..................................................................................................................................................................- 48 Specialty Referrals .................................................................................................................................................................- 49 Second Opinions ....................................................................................................................................................................- 49 Specialty Care Providers ........................................................................................................................................................- 50 Role and Responsibility of the Specialty Care Provider .........................................................................................................- 51 Specialty Care Providers Access and Availability ...................................................................................................................- 52 Open-Access Specialist Providers ..........................................................................................................................................- 53 Cultural Competency .............................................................................................................................................................- 53 Marketing ..............................................................................................................................................................................- 53 Member Records ...................................................................................................................................................................- 54 Medical Record Standards ..............................................................................................................................................- 55 Patient Visit Data ...................................................................................................................................................................- 58 Clinical Practice Guidelines ....................................................................................................................................................- 59 Advance Directives ................................................................................................................................................................- 60 Telemedicine..........................................................................................................................................................................- 61 MEDICAL MANAGEMENT ............................................................................................................................................... - 62 Medical Review Criteria .........................................................................................................................................................- 62 Clinical Criteria ................................................................................................................................................................- 63 Precertification/Notification Process.....................................................................................................................................- 63 HOSPITAL AND ELECTIVE ADMISSION MANAGEMENT ................................................................................................... - 60 Emergent Admission Notification Requirements ..................................................................................................................- 61 Nonemergent Outpatient and Ancillary Services: Precertification and Notification Requirements .....................................- 61 Inpatient Reviews ..................................................................................................................................................................- 72 Inpatient Admission Review ...........................................................................................................................................- 72 Inpatient Concurrent Review ..........................................................................................................................................- 72 Discharge Planning.................................................................................................................................................................- 73 Confidentiality of Information ...............................................................................................................................................- 73 Emergency Services ...............................................................................................................................................................- 73 Urgent Care ............................................................................................................................................................................- 74 QUALITY MANAGEMENT ............................................................................................................................................... - 75 Quality Management Program ..............................................................................................................................................- 75 Overview .........................................................................................................................................................................- 75 Quality of Care ................................................................................................................................................................- 75 Use of performance data ................................................................................................................................................- 75 Quality Management Committee ..........................................................................................................................................- 76 Medical Advisory Committee ................................................................................................................................................- 77 Provider Orientation and Education ...............................................................................................................................- 77 Medical Record Documentation Review Standards ..............................................................................................................- 78 Administrative Component ............................................................................................................................................- 78 Infection Prevention ............................................................................................................................................................- 101 Risk Management ................................................................................................................................................................- 102 Internal Incident Reporting System ..............................................................................................................................- 103 Definitions ....................................................................................................................................................................- 103 Reporting Responsibilities ............................................................................................................................................- 104 Procedural Responsibilities...........................................................................................................................................- 104 Incident Report Review and Analysis ...........................................................................................................................- 105 Credentialing ........................................................................................................................................................................- 105 Credentialing Requirements .........................................................................................................................................- 106 -
Credentialing Procedures .............................................................................................................................................- 106 Credentialing Organizational Providers ........................................................................................................................- 109 Delegated Credentialing ...............................................................................................................................................- 110 Peer Review ..................................................................................................................................................................- 111 MEMBER APPEAL AND GRIEVANCE PROCEDURES ....................................................................................................... - 112 Complaints and Grievances .................................................................................................................................................- 112 Medical Appeals...................................................................................................................................................................- 114 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES .............................................................................................. - 117 Electronic Submission ..........................................................................................................................................................- 117 Paper Claims Submission .....................................................................................................................................................- 117 Encounter Data ....................................................................................................................................................................- 118 Claims Adjudication .............................................................................................................................................................- 119 Clean Claims Payment .........................................................................................................................................................- 119 Claims Status ........................................................................................................................................................................- 120 Provider Reimbursement .....................................................................................................................................................- 120 Increased Medicaid Payments for Primary Care Physicians and Eligible Providers .....................................................- 120 Electronic Funds Transfer and Electronic Remittance Advice ......................................................................................- 121 PCP Reimbursement .....................................................................................................................................................- 121 Specialist Reimbursement ............................................................................................................................................- 121 Provider Payment Disputes .................................................................................................................................................- 121 Coordination of Benefits ......................................................................................................................................................- 123 Billing Members ...................................................................................................................................................................- 123 Client Acknowledgment Statement ..............................................................................................................................- 125 Amerigroup Website and the Provider Inquiry Line ............................................................................................................- 125 APPENDIX A — FORMS ................................................................................................................................................ - 126 Medical Record Forms .........................................................................................................................................................- 127 Specialist as PCP Request Form ....................................................................................................................................- 128 Precertification Request Form ......................................................................................................................................- 129 Incident Report Form....................................................................................................................................................- 131 Medical Record Review Checklist .................................................................................................................................- 132 Medical Documentation Forms ....................................................................................................................................- 133 Pediatric Periodicity Forms ..................................................................................................................................................- 134 American Academy of Pediatrics – Bright Futures Periodicity Schedule ......................................................................- 135 Centers for Disease Control Immunizations Schedule for Persons Aged 0-18 .............................................................- 136 HIV Antibody Blood Forms ...................................................................................................................................................- 142 Counsel for HIV Antibody Blood Test ...........................................................................................................................- 143 Consent for the HIV Antibody Blood Test .....................................................................................................................- 144 Results of the HIV Antibody Blood Test ........................................................................................................................- 145 Hysterectomy and Sterilization Forms .................................................................................................................................- 146 Sterilization Consent Form ...........................................................................................................................................- 147 Hysterectomy Acknowledgement Form .......................................................................................................................- 148 Abortion Certification Form .................................................................................................................................................- 149 Durable Power of Attorney (English) ...................................................................................................................................- 150 Durable Power of Attorney (Spanish) ..................................................................................................................................- 151 Living Will (Florida Declaration) ...........................................................................................................................................- 152 Testamento Médico en Vida (Declaración de Florida) ........................................................................................................- 153 Advance Directive (English) .................................................................................................................................................- 154 Advance Directive (Spanish) ................................................................................................................................................- 155 Provider Payment Dispute and Correspondence Form .......................................................................................................- 156 APPENDIX B — CLINICAL PRACTICE GUIDELINES .......................................................................................................... - 157 ADDITIONAL FORMS .................................................................................................................................................... - 158 Medicare Forms ............................................................................................................................................................- 158 -
Referral and Claim Submission Forms ..........................................................................................................................- 158 Precertification Forms ..................................................................................................................................................- 158 Provider Grievances and Appeals Forms ......................................................................................................................- 158 Medical Record Documentation Forms ........................................................................................................................- 158 Other Forms ..................................................................................................................................................................- 158 Pharmacy Synagis Order Form .....................................................................................................................................- 159 Behavioral Health Forms ..............................................................................................................................................- 159 Hysterectomy and Sterilization Forms .........................................................................................................................- 159 Cost Containment Form................................................................................................................................................- 159 -
INTRODUCTION
Amerigroup Community Care would like to welcome you to the Florida Statewide Medicaid Managed Care
(SMMC) Managed Medical Assistance (MMA) provider network family. We are pleased you joined our
network, which represents some of the finest providers in the country.
We bring the best expertise available nationally to operate local community-based health care plans with
experienced local staff to complement our operations. We are committed to helping you provide quality
care and services to our members. We believe hospitals, physicians and other providers play a pivotal
role in managed care. Amerigroup can only succeed by working collaboratively with you and other
caregivers. Earning your loyalty and respect is essential to maintaining a stable, high-quality provider
network. All network providers are contracted with Amerigroup through a participating provider
agreement.
Note: This provider manual does not apply to members of the Medicare Advantage or the SMMC
Long-Term Care (LTC) program. For more information about providing services to Medicare
Advantage members, call 1-800-563-5581. For more information about providing services to LTC
members, call 1-877-440-3738.
--1-FL-PM-0024-14
OVERVIEW
Who Is Amerigroup?
As a leader in managed health care services for the public sector, we provide health care coverage
exclusively to low-income families, children, pregnant women, Medicare Advantage Plans and
Medicare Special Needs Plans. We participate in Medicare, Florida Healthy Kids, SMMC-LTC and the
SMMC-MMA programs.
Mission
Together, we are transforming health care with trusted and caring solutions.
Strategy
Our strategy is to:
 Improve access to preventive primary care services by ensuring the selection of a primary care
physician who will serve as provider, care manager and coordinator for all basic medical services
 Improve the health status and outcomes of members
 Educate members about their benefits, responsibilities and the appropriate use of health care
services
 Encourage stable, long-term relationships between providers and members
 Discourage medically inappropriate use of specialists and emergency rooms
 Commit to community-based enterprises and community outreach
 Facilitate the integration of physical and behavioral health care
 Foster quality improvement mechanisms that actively involve providers in re-engineering health
care delivery
 Encourage a customer service orientation with regular measurement of member and provider
satisfaction
Summary
The 2011 Florida Legislature passed House Bill 7107 (creating part IV of Chapter 409, F.S.) to establish
the Florida Medicaid program as a statewide, integrated managed care program for all covered
services, including long-term care services. This program is referred to as Statewide Medicaid Managed
Care (SMMC) and includes two programs: one for Managed Medical Assistance (MMA) and one for
long-term care (LTC) consistent with our mission.
The goals of the SMMC-MMA program are to provide:
• Coordinated health care across different health care settings
• A choice of the best-managed care plans to meet recipients’ needs
• The ability for health care plans to offer different, or more, services
• The opportunity for recipients to become more involved in their health care
FL-PM-0024-14
--2--
QUICK REFERENCE INFORMATION
Please call Provider Services at the National Customer Care department for precertification/
notification, health plan network information, member eligibility, claims information, inquiries and
recommendations you may have about improving our processes and managed care program.
Amerigroup Phone Numbers
Provider Services at the National Customer Care department telephone: 1-800-454-3730
Provider Services at the National Customer Care department fax: 1-800-964-3627
AT&T Relay Service: 1-800-855-2880 (English); 1-800-855-2884 (Spanish)
Automated Provider Inquiry Line for Member Eligibility: 1-800-454-3730
Electronic Data Interchange (EDI) Hotline: 1-800-590-5745
Nurse HelpLine: 1-800-600-4441
Member Services: 1-800-600-4441
Pharmacy Services: 1-800-454-3730
Other Telephone Numbers
eyeQuest (vision): 1-888-696-9551
DentaQuest (dental): 1-877-468-5581
HearUSA (hearing): 1-877-664-9353
Vaccines for Children: 1-800-483-2543
Immunization Registry (SHOTS): 1-877-888-SHOT (1-877-888-7468)
It’s Great to Wait Pregnancy Prevention Program: 1-866-232-3309
Healthy Start Program: 1-800-541-BABY (toll free), 386-758-1135 (or the local health department)
Women, Infants, and Children and Nutritional Service: 1-800-342-3556
Univita (durable medical equipment, home health and home infusion services): 1-866-887-7667
Florida Quitline (smoking cessation): 1-877-U-CAN-NOW (1-877-822-6669)
Chiro Alliance (chiropractic care): 727-319-6199
Express Scripts (pharmacy benefit manager): 1-800-824-0898
LabCorp: 1-800-877-5227
Quest: 1-800-377-8448
FL-PM-0024-14
--3--
Elder Abuse Hotline: 1-800-96Abuse (1-800-962-2873)
LogistiCare (transportation): 1-866-372-9794
Amerigroup Website
Our website contains the full complement of online provider resources. The website features an online
provider inquiry tool for real-time information about member eligibility, prior authorization requests,
claims status, claims resubmission and claims disputes. You can also submit demographic changes and
provider rosters. In addition, the website has other resources and materials to help you work with us,
including provider forms, a preferred drug list, a list of drugs requiring prior authorization, provider
manuals, referral directories, a provider newsletter, electronic remittance advice and electronic funds
transfer information, updates, and clinical practice guidelines. Visit our website at
providers.amerigroup.com/FL.
Provider Experience Program
To thank you for the quality of care you give our members, we work to continuously increase service
quality for you. Our new Provider Experience Program, focused on claims payment and issue
resolution, does just that!
Call 1-800-454-3730 with claims payment questions or issues.
The Provider Experience Program support model connects you with a dedicated resource team to
ensure:
 Availability of helpful, knowledgeable representatives to assist you
 Increased first-contact and issue-resolution rates
 Significantly improved turnaround time of inquiry resolution
 Increased outreach communications to keep you informed of your inquiry status
Ongoing Provider Communications
In order to ensure you are up-to-date with information required to work effectively with us and our
members, we provide frequent communications in the form of broadcast faxes, provider manual
updates, newsletters and information posted to the website.
The additional information below will help you in your day-to-day interaction with Amerigroup.
Additional Information
Member Eligibility
Member
Enrollment/Disenrollment
FL-PM-0024-14
Contact the Provider Inquiry Line at 1-800-454-3730 or visit our
website at providers.amerigroup.com/FL
Medicaid Recipients can enroll in Amerigroup online at:
www.flmedicaidmanagedcare.com or by contacting the numbers listed
below:
 1-877-711-3662 (Phone)
 1-866-467-4970 (TTY)
Florida Healthy Kids members should contact the Florida Healthy Kids
--4--
Additional Information
Notification/Precertification
Claims Information
Corporation at 1-800-821-5437
 Precertification requests may be telephoned, submitted online or
faxed to Amerigroup:
– Telephone: 1-800-454-3730
– Fax: 1-800-964-3627
– providers.amerigroup.com/FL
 The
following
data
are
required
for
complete
notification/precertification:
– Member ID
– Legible name of referring provider
– Legible name of individual referred to provider
– National provider identifier and/or tax ID number
– Number of visits/services
– Date(s) of service
– Diagnosis
– Current
Procedural
Terminology/Healthcare
Common
Procedure Coding System (CPT/HCPCS) codes
 In addition, clinical information is required for precertification
Referral and authorization forms are available
providers.amerigroup.com/FL.
 Submit paper claims to:
Florida Claims
Amerigroup Community Care
P.O. Box 61010
Virginia Beach, VA 23466-1010

online
at
Electronic claims payer ID:
– Emdeon (formerly WebMD) is 27514
– Capario (formerly MedAvant) is 28804
– Availity (formerly THIN) is 26375
For EDI assistance, providers may call the EDI hotline at
1-800-590-5745.
 Timely filing is within 180 days of the date of service or per the
terms of the provider agreement
 Amerigroup provides an online resource designed to significantly
reduce the time your office spends on eligibility verification, claims
status and authorization status. Visit our website at
providers.amerigroup.com/FL.
 If you are unable to access the Internet, you may receive claims,
eligibility and authorization status over the telephone at any time
by calling our toll-free, automated Provider Services line at
1-800-454-3730
FL-PM-0024-14
--5--
Additional Information
Medical Appeal Information
Payment Dispute

Medical appeals may be initiated by the member or provider on
behalf of the member and must be submitted within 30 calendar
days from the date of an adverse determination

Submit medical appeals to:
Medical Appeals
Amerigroup Community Care
P.O. Box 62429
Virginia Beach, VA 23466-2429
Providers have 120 calendar days from receipt of an Explanation of
Payment (EOP) or utilization denial letter to request a first-level
appeal. Amerigroup will send a determination letter within 30
business days of receiving all necessary information. If the provider
is dissatisfied with the resolution, the provider may submit an
appeal of the resolution within 30 calendar days of the date on the
resolution letter
Our Provider Experience program also helps you with claims
payment and issue resolution. Just call 1-800-454-3730 and select
the Claims prompt within our voice portal. The Provider
Experience program connects you with a dedicated resource team
to ensure:
– Availability of helpful, knowledgeable representatives to assist
you
– Increased first-contact, issue resolution rates
– Significantly improved turnaround time of inquiry resolution
– Increased outreach communication to keep you informed of
your inquiry status



Grievances
Case Managers
Provider Services
Representatives
FL-PM-0024-14
File a payment dispute to:
Payment Disputes
Amerigroup Community Care
P.O. Box 61599
Virginia Beach, VA 23466-1599
 Provider grievances should be submitted to:
Provider Relations
Amerigroup Community Care
4200 W. Cypress St., Suite 900
Tampa, FL 33607
 Amerigroup case managers are available during normal business
hours from 8 a.m. to 5 p.m. Eastern time
 For urgent issues, assistance is available after normal business
hours, on weekends and on holidays through the Provider Services
line at 1-800-454-3730
For more information, contact Provider Services at the National
Customer Care department at 1-800-454-3730.
--6--
PRIMARY CARE PHYSICIANS
Primary Care Physicians
The primary care physician (PCP) is a network physician who has the responsibility for the complete
care of his or her patient, who is an Amerigroup member. The PCP serves as the entry point into the
health care system for the member. The PCP is responsible for the complete care of his or her patient,
including but not limited to providing primary care, coordinating and monitoring referrals to specialist
care, authorizing hospital services, and maintaining continuity of care. The PCP’s responsibilities shall
include at a minimum:
 Managing the medical and health care needs of members to ensure that all medically necessary
services are made available in a timely manner
 Monitoring and following up on care provided by other medical service providers for diagnosis and
treatment, including services available under Medicaid fee-for-service
 Providing the coordination necessary for the referral of patients to specialists and for the referral of
patients for services that may be available through fee-for-service Medicaid
 Maintaining a medical record of all services rendered by the PCP and other referral providers
 Seeing newly enrolled pregnant members within 30 days of enrollment
A PCP must be a physician or network provider/subcontractor who provides or arranges for the
delivery of medical services, including case management, to ensure that all medically necessary
services are made available in a timely manner. The PCP may practice in a solo or group setting or may
practice in a clinic (e.g., a Federally Qualified Health Center [FQHC] or Rural Health Center [RHC] or
outpatient clinic).
Amerigroup encourages enrollees to select a PCP who provides preventive and primary medical care,
as well as authorization and coordination of all medically necessary specialty services. Members are
encouraged to make an appointment with their PCP within 90 calendar days of their effective date of
enrollment.
FQHCs and RHCs may function as a PCP. Providers must arrange for coverage of services to assigned
members:
 24 hours a day, 7 days a week in person or by an on-call physician
 By answering emergency telephone calls from members within 30 minutes
 By providing a minimum of 20 office hours per week of personal availability as a PCP
Provider Specialties
Physicians with the following specialties can apply for enrollment with Amerigroup as a PCP:
 Family practitioners
 Practitioners certified as specialists in family
practice or pediatrics
 General practitioners
 FQHCs and RHCs
 General pediatricians
 Obstetricians/gynecologists (OB/GYNs) (for
 General internists
women when they are pregnant)
 Advanced registered nurses
 Nurse practitioners
The provider must be enrolled in the Medicaid program at the service location where he or she wishes
to practice as a PCP before contracting with Amerigroup.
FL-PM-0024-14
--7--
A provider must be a board-certified pediatrician or family practitioner if he or she wishes to practice
as a Florida Healthy Kids PCP (unless granted an exemption by the Florida Healthy Kids Corporation
board of directors).
Our primary care network may also include PCPs who (1) have recently completed a residency program
in pediatrics or family practice approved by the National Board for Certification of Training
Administrators of Graduate Medical Education programs and (2) are eligible for but have not yet
achieved board certification. If a PCP does not achieve board certification within the first three years of
initial credentialing, we will remove that provider from our network and reassign members to a boardcertified PCP.
All PCPs in our network must provide all covered immunizations to Amerigroup members and be
enrolled in the Florida State Health Online Tracking System (SHOTS), the statewide immunization
registry.
Primary Care Physician Onsite Availability
Amerigroup is dedicated to ensuring access to care for our members, and this depends upon the
accessibility of network providers. Amerigroup network providers are required to abide by the
following standards:
 PCPs must offer telephone access to member 24 hours a day, 7 days a week
 A 24-hour telephone service may be utilized. The service may be answered by a designee such as
an on-call physician or nurse practitioner with physician backup, an answering service or a pager
system; however, this must be a confidential line for member information and/or questions. An
answering machine is not acceptable. If an answering service or pager system is used, the call must
be returned within 30 minutes.
 The PCP or another physician/advanced registered nurse practitioner must be available to provide
medically necessary services
 Covering physicians are required to follow the referral/precertification guidelines
 It is not acceptable to automatically direct the member to the emergency room when the PCP is
not available
 We encourage our PCPs to offer after-hours office care in the evenings and on weekends
Provider Disenrollment Process
Providers may cease participation with Amerigroup for either mandatory or voluntary reasons.
Mandatory disenrollment occurs when a provider becomes unavailable due to immediate, unforeseen
reasons. Examples of this include illness and/or death. A notice to affected members will be issued
immediately upon the health plan becoming aware of the situation. Should a provider cease
participation for a voluntary reason such as retirement, a written notice to the affected members will
be issued no less than 90 calendar days prior to the effective date of the termination and no more than
10 calendar days after receipt or issuance of the termination notice.
If a member is in a preauthorized, ongoing course of treatment with the provider who ceases
participation, Amerigroup will notify the member in writing within 10 calendar days from the date that
Amerigroup becomes aware of the provider’s network status.
FL-PM-0024-14
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Member Enrollment
Members who meet the state’s eligibility requirements for participation in managed care are eligible to join
the Amerigroup health care plan. Members are enrolled without regard to the applicant’s health status.
Members are enrolled for a period of 12 months, contingent upon continued eligibility. The member
may request disenrollment without cause at any time during the 90 days following the date of the
member’s initial enrollment with Amerigroup or upon enrollment reinstatement or agency approval.
Unless the member loses eligibility or submits an oral or a written disenrollment request to change
managed care plans for cause, the member remains enrolled in a health plan for the remainder of the
12-month period. Amerigroup will ensure that all written and oral disenrollment requests are promptly
referred to Florida Statewide Medicaid Managed Care (SMMC).
Within three business days, Amerigroup will send notification of any written request received by
Amerigroup to the member in the form of a letter advising the member to call enrollment and
disenrollment services at SMMC at 1-877-771-3662 (phone)/1-866-467-4970 (TTY).
For member enrollment for Florida Healthy Kids, please call 1-800-821-KIDS (5437).
Involuntary Disenrollment
Involuntary disenrollment may occur under the following conditions:
 Member is deceased
 Member’s Medicaid ID card is fraudulently used
 Member relocates out of the service area
 Member loses Medicaid eligibility
 Member is admitted to a long-term facility or hospital
 Member enrolls in another Medicaid/Medicare Health Maintenance Organization (HMO)
 Member’s Medicaid eligibility has been determined through the medically needy program
 Member’s eligibility is under the Qualified Medicare Beneficiaries (QMBs) program
 Member has other major medical insurance (e.g., CHAMPUS, private HMO)
 Member takes part in disruptive and abusive behavior
 Member fails to follow a proposed plan of medical care
Action related to a request for involuntary disenrollment conditions must be clearly documented in the
member’s records and submitted to the local Amerigroup Provider Operations department. The
documentation must include attempts to bring the member into compliance. A member’s failure to
comply with a written corrective action plan must be documented. The member must have at least one
verbal and one written warning regarding the implications of his or her actions. Amerigroup must be
notified before transferring a member out of a physician’s practice. The Agency for Health Care
Administration (AHCA) will be responsible for processing disenrollments.
For any action to be taken, it is mandatory that copies of all supporting documentation from the
member’s file be submitted with the request.
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Newborn Enrollment
All Medicaid-eligible newborns of members are the responsibility of Amerigroup. We will be
responsible for payment of medically necessary services and well-child care for the newborn from the
date of his or her birth. Amerigroup must be notified by the Department of Children and Family
Services (DCF) of the newborn’s Medicaid ID number, and activation of the ID number by Medicaid is
necessary to complete the member’s enrollment. Once enrolled, Amerigroup will remain responsible
for the newborn, regardless of the mother’s Medicaid eligibility or HMO enrollment status, for the
birth month and the next two consecutive months unless the mother voluntarily disenrolls the
newborn from the health plan, the newborn loses Medicaid eligibility or the newborn is enrolled by the
mother in Children’s Medicaid Services.
Amerigroup and the hospital will follow the unborn/newborn activation process below for newborn
enrollment:
1. Upon identification of an enrollee's pregnancy through medical history, examination, testing,
claims, or otherwise, we will immediately notify DCF of the pregnancy and any relevant information
known (for example, due date and gender). We must provide this notification by completing the
DCF Excel spreadsheet and submitting it, via electronic mail, to the appropriate DCF Customer Call
Center address and copied to MPI at email: [email protected] We shall indicate its
name and number as the entity initiating the referral.
a. The DCF Excel spreadsheet and directions for completion are located on the Medicaid web
site: http://ahca.myflorida.com/Medicaid/Newborn/index.shtml.
2. DCF will generate a Medicaid ID number for the unborn child. This information will be transmitted
to the Medicaid fiscal agent. The Medicaid ID number will remain inactive until the child is born and
DCF is notified of the birth.
3. Upon notification that a pregnant enrollee has presented to the hospital for delivery, Amerigroup
shall inform the hospital, the pregnant enrollee's attending physician and the newborn's attending
and consulting physicians that the newborn is an enrollee. At this time, Amerigroup or our designee
shall complete and submit the Excel spreadsheet for unborn activation to DCF, and to MPI for its
information.
Members Eligibility Listing
The PCP can review his or her panel of assigned members online; to receive a listing of assigned panel
members by mail on the first day of each month, the PCP must request the list from his or her Provider
Relations representative. The list will consist of Amerigroup members who have chosen the PCP’s
office to provide services. If a member calls to change his or her PCP, the change will be effective the
next business day. The PCP should verify that each Amerigroup member receiving treatment in his or
her office is on the membership listing. If a PCP does not receive the listing in a timely manner, he or
she should contact a Provider Relations representative. For questions regarding a member’s eligibility,
providers can access our provider website at providers.amerigroup.com/FL or call the automated
Provider Inquiry Line at 1-800-454-3730.
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Member ID Cards
Each Amerigroup member will be provided an ID card within 14 calendar days of notification of
enrollment into Amerigroup or prior to the member’s enrollment effective date. The ID card identifies
the member as a participant in the Amerigroup program. To ensure immediate access to services,
providers must accept the member’s Medicaid managed care ID card as proof of enrollment in the
Amerigroup plan until the member receives the member ID card from Amerigroup. The holder of the
member ID card issued by Amerigroup is a member or guardian of the member. The ID card will
include:
 The member’s ID number
 The member’s name (first and last names and middle initial)
 The member’s date of birth
 The member’s enrollment effective date
 Toll-free phone numbers for information and/or authorizations
 Toll-free Nurse HelpLine information; the line is accessible 24 hours a day, 7 days a week
 Descriptions of procedures to be followed to obtain emergency or specialty services
 Amerigroup address and telephone number
 The PCP’s name, address and telephone number
Americans with Disabilities Act Requirements
Amerigroup policies and procedures are designed to promote compliance with the Americans with
Disabilities Act of 1990. Providers are required to take actions to remove an existing barrier and/or to
accommodate the needs of members who are qualified individuals with a disability. This action plan
includes:
 Street-level access
 An elevator or accessible ramp into facilities
 Access to a lavatory that accommodates a wheelchair
 Access to an examination room that accommodates a wheelchair
 Handicapped parking space(s) that are clearly marked, unless there is street-side parking
Medically Necessary Services
Medically necessary health services mean health services that are:
 Necessary to protect life, to prevent significant illness or significant disability or to alleviate severe
pain
 Individualized, specific and consistent with symptoms or confirm diagnosis of the illness or injury
under treatment and not in excess of the patient's needs
 Consistent with the generally accepted professional medical standards as determined by the
Medicaid program, and not be experimental or investigational
 Reflective of the level of service that can be furnished safely and for which no equally effective and
more conservative or less costly treatment is available statewide
 Furnished in a manner not primarily intended for the convenience of the enrollee, the enrollee's
caretaker or the provider
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For services furnished in a hospital on an inpatient basis, medical necessity means appropriate medical
care cannot be effectively furnished more economically on an outpatient basis or in an inpatient facility
of a different type.
The fact that a provider has prescribed, recommended or approved medical, allied, or long-term care
goods or services does not, in itself, make such care, goods or services medically necessary, a medical
necessity or a covered service/benefit.
Continuity of Care
We will observe a 60-day continuity of care waiver for all MMA services. No service will be denied for
absence of authorization in circumstances where care was in place prior to the transition date.
The continuity of care waiver applies to both participating and nonparticipating Amerigroup providers.
The service is continued until we assess the member and reauthorize and/or transfer him or her to a
participating provider. Once we assess the member, the new authorization will be observed and will
drive future claims payment.
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AMERIGROUP HEALTH CARE BENEFITS AND COPAYMENTS
Amerigroup Covered Services
Any modification to covered services will be distributed via a provider update by mail, fax, provider
newsletter, provider manual addendum and/or contractual amendment. Covered services include the
following list and may vary by product:
 Advanced registered nurse practitioner
 Home health services and nursing care
 Ambulatory surgical center services
 Hospice services
 Assistive care services
 Hospital services
 Behavioral health services
 Laboratory and imaging services
 Birth center and licensed midwife services
 Medical supplies, equipment, prostheses
 Clinic services
and orthoses
 Chiropractic services
 Optometric and vision services
 Dental services
 Physician assistant services
 Child health check up
 Physician services
 Immunizations
 Podiatric services
 Emergency services
 Prescribed drug services
 Emergency behavioral health services
 Renal dialysis services
 Family planning services and supplies
 Therapy service
 Healthy start services
 Transportation services
 Hearing services
The scope of benefits is described in more detail in the quick reference card posted on the Amerigroup
website at providers.amerigroup.com/FL.
Enhanced Benefits
Amerigroup has decided to offer a group of enhanced benefits. The expanded services identified below
are additional benefits not included in the Florida MMA/Florida Healthy Kids (FHK) core benefits.
If copayments are waived as an expanded benefit, you must not charge the member copayments for
covered services. If copays are not waived as an expanded benefit, the amount paid to you will be the
contracted amount or, for fee-for-service providers, the Medicaid fee schedule amount less any
applicable copays.
Covered Services
Hearing services
Vision care
FL-PM-0024-14
Description
MMA:
Sixty (60) hearing aid batteries per year; includes battery size(s): 10, 13, 312
and 675; subject to medical necessity.
FHK:
No copayment is required.
MMA:
 Examination, diagnosis, treatment, and management of ocular and
adnexal pathology
 Visual examinations to determine the need for eyeglasses
 Members age 21 years and older are covered for an extra $100 for
contact lenses and contact lens services, as medically necessary
 Visual services include the medically necessary provision of optical
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Covered Services
Respite care
Healthy Families
Program
Hypoallergenic
bedding
Mouthguards
Maternity case
management
Annual exams
Amerigroup On Call
Description
services and supplies such as eyeglasses, prosthetic eyes, and contact
lenses
 Fitting, dispensing, and adjusting of eyeglasses, and eyeglass repair
services are also covered
FHK:
Covered services include an eye exam plus corrective lenses and frames if
medically needed.
 No copayment is required for routine eye exams provided by the Primary
Care Provider (PCP)
 $5 copayment is required per specialist visit
 $10 copayment is required for corrective lenses
MMA:
Annual maximum of not more than an initial home health visit by a registered
nurse at $65 and eight follow-up visits by an aide at $23 per visit. Follow-up
visits are four hours in length. Maximum of 16 hours in a given month and 32
hours per year.
FHK:
Six months of fitness and healthy behavior coaching is covered for members
ages 7–13.
FHK:
Covered services include up to $100 maximum per lifetime toward the
purchase of hypoallergenic bedding. Coverage is limited to FHK members with
a diagnosis of asthma or severe allergies. You will need to verify eligibility
with Amerigroup by calling us at 1-800-454-3730. A Provider Services
representative will provide additional instructions once eligibility is verified.
The member will need to have a prescription to obtain the allergy bedding.
FHK:
Mouthguards are free for members involved in contact sports.
MMA and FHK:
Specialized case management is covered for high-risk pregnant members.
FHK:
Members receive free annual checkups or school physicals.
MMA and FHK:
Members have access to a 24-hour Nurse HelpLine and physician
consultations to answer their medical questions day and night. This service
can help members:
• Find doctors when your office is closed, whether after hours or on
weekends
• Schedule appointments with you or other network doctors
• Get to urgent care centers or walk‐in clinics
• Speak directly with an Amerigroup On Call doctor or a member of the
doctor’s staff to talk about their health care needs
We encourage you to tell your Amerigroup patients about this service and
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Covered Services
Description
share with them the advantages of avoiding the ER when a trip there isn’t
necessary or the best alternative.
Members can reach Amerigroup On Call at 1‐866‐864‐2544
(TTY 1-800-855-2880). Language translation services are also available
through the Amerigroup On Call line.
Primary care services MMA and FHK:
There is no copay to see a PCP and no limit to the number of primary care
visits.
Home Health Care
MMA:
(Non-Pregnant Adults) Unlimited visits; subject to medical necessity and prior authorization.
Physician Home Visits MMA:
Unlimited visits; limited to adult, homebound enrollees who otherwise require
ambulance transport to access primary care.
Prenatal/Perinatal
MMA:
Visits
Unlimited visits.
MMA:
Outpatient Services
No monetary limit on outpatient services; subject to medical necessity; subject
to prior authorization with the exception of laboratory services.
MMA:
Over-The-Counter
(OTC) Medication and Twenty-five dollars ($25) per enrollee household per month.
Supplies
Adult Dental Services MMA:
One exam every six months; one cleaning every six months.
For SSI non-Medicaid/Medicare dual-eligible enrollees:
One set of bitewings per year; unlimited fillings, limit one filling per tooth
every 36 months; one fluoride treatment every six months.
Waived Copayments MMA:
Enrollees shall not be subject to co-payment charges.
MMA:
Vision Services
One hundred dollars ($100) per year for contact lenses and contact lens
services; limited to adult enrollees; subject to medical necessity.
Newborn Circumcision MMA:
Available upon request up to 28 days old; does not require prior authorization.
MMA:
Adult Pneumonia
One vaccination per lifetime without prior authorization; one vaccine every
Vaccine
five years subject to prior authorization.
Adult Influenza
MMA:
Vaccine
One vaccination per year.
Adult Shingles Vaccine MMA:
One vaccination per lifetime; limited to enrollees aged 60 and older.
Post Discharge Meals MMA:
Two meals per day for seven days; limited to adult enrollees following being
discharged from a surgical hospital stay of at least three (3) days.
Nutritional Counseling MMA:
One visit every three months to a maximum of four visits per year.
Art Therapy
MMA:
Unlimited visits.
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Taking Care of Baby and Me Program
Amerigroup offers Taking Care of Baby and Me® to all expectant mothers. The program’s objective is to
provide coordinated, comprehensive prenatal management with the intent of identifying members
prior to an adverse health event and providing them with care management, education and incentive
gift rewards to promote healthy outcomes.
Prenatal Program
A package will be sent upon enrollment into the Taking Care of Baby and Me program that includes a
pregnancy book. Upon completing prenatal checks, members are eligible for a $10 gift card (e.g.,
Walmart, Target).
Postpartum Program
The member will also receive a Taking Care of Baby and Me postpartum book. Upon completing the
postpartum check between 21 and 56 days post-delivery by her doctor, the member will be mailed an
incentive gift for keeping her appointment.
Notification to the Amerigroup National Customer Care department at 1-800-454-3730 is required at
the first prenatal visit. Taking Care of Baby and Me provides care management to:
 Improve the member’s level of knowledge about her pregnancy
 Create systems that support the delivery of quality care
 Measure and maintain or improve member outcomes related to the care delivered
 Facilitate care with providers to promote collaboration, coordination and continuity of care
Health education is provided and encouraged through prenatal and postpartum health promotion
packets that also include information on foster program participation and gift incentives. Information
about available health-related community services is provided to members as appropriate. All
identified pregnant members will automatically receive information on Taking Care of Baby and Me.
Quality Enhancement Program
Amerigroup offers quality-enhanced programs for the benefit of members and providers. These include:
1. Children’s programs — We provide regular general wellness programs for ages birth to 5 years, or
we make a good faith effort to involve members in existing community children’s programs.
a. We rely on providers seeing children to provide prevention and early intervention services for
at-risk members. We approve claims for services recommended by the early intervention
programs when they are covered services and medically necessary.
b. We offer annual training to providers (through monthly provider agendas, the Amerigroup
website, etc.) that promote proper nutrition, breast-feeding, immunizations, CHCUP, wellness,
prevention and early intervention services.
2. Domestic violence programs — We require PCPs to screen members for signs of domestic violence and
require PCPs to offer referral services to applicable domestic violence prevention community agencies.
3. Pregnancy prevention — We conduct pregnancy prevention programs or shall make a good faith
effort to involve members in existing community pregnancy prevention programs. These programs
will be targeted toward teen enrollees but be open to all ages.
4. Prenatal/postpartum pregnancy programs — We provide regular home visits by a home health nurse
or aide and offer counseling and educational materials to pregnant and postpartum members who
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are not in compliance with the health plan’s prenatal and postpartum programs. We will coordinate
our efforts with the local Healthy Start care coordinator to prevent duplication of services.
5. Smoking cessation — We provide smoking cessation counseling to members. We provide
participating PCPs with a quick reference card to help identify tobacco users and support delivery of
effective smoking cessation interventions. Please see the Smoking Cessation Program section below.
6. Substance abuse programs — We offer annual substance abuse screening training to our providers.
In addition, several screening tools and other resources are available on our provider website to
help providers identify substance abuse and make appropriate referrals.
a. At a minimum, all PCPs are required to screen members for signs of substance abuse as part of
prevention evaluation at the following times:
i) During initial contact with a new member
ii) During routine physical examinations
iii) During initial prenatal contact
iv) When the member displays serious overutilization of medical, surgical, trauma or
emergency services
v) When documentation of emergency room visits suggests the need
b. Providers identifying patients with substance abuse needs should refer patients to community
substance abuse programs
Well-child Visits/Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Amerigroup members are encouraged to contact their physician within the first 90 days of enrollment
to schedule a well-child visit and within 24 hours for newborns. Amerigroup members are eligible to
receive these services from birth to age 20. The well-child program in Florida is known as Child Health
Check-Ups (CHCUP) and provides the following:
 Comprehensive health and development history
 Physical and mental development assessment
 Comprehensive unclothed physical examination
 Age-appropriate immunizations
 Appropriate laboratory tests
 Health education
Newborn well-child services should be performed for newborns in the hospital and then at the
following ages:
 Between 1 to 2 weeks
 6 months
 1 month
 9 months
 2 months
 12 months
 4 months
In the child’s second year of life, he or she should see a PCP at 15 months, 18 months and 24 months of
age. During the span of a child’s third year of life until age 20, the child should be seen by his or her
PCP at least on an annual basis. Amerigroup educates our members about these guidelines and
monitors encounter data for compliance.
Amerigroup recommends that participating providers who treat children under the age of 21 to utilize
the American Academy of Pediatrics Bright Futures Well-Child Forms to ensure all aspects of an EPSDT
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visit are captured. The forms can be found at http://brightfutures.aap.org (Tools and Resources) or
under Appendix A of this manual.
Amerigroup requires providers to:
 Participate in the CHCUP program if they treat children under the age of 21
 Provide all needed initial, periodic and interperiodic EPSDT health assessments, diagnosis and
treatment to all eligible members in accordance with the Florida Agency for Health Care
Administration’s approved Medicaid administrative regulation Sect. III C.9.b and the periodicity
schedule provided by the American Academy of Pediatrics (AAP)
 Refer members to an out-of-network provider for treatment if the service is not available within
our network
 Provide vaccines and immunizations in accordance with the Advisory Committee on Immunization
Practices (ACIP) guidelines
 Provide vaccinations in conjunction with EPSDT/well-child visits; providers are required to use
vaccines available without charge under the Vaccine for Children (VFC) program for Medicaid
children 18 years of age and younger
 Address unresolved problems, referrals and results from diagnostic tests, including results from
previous EPSDT visits
 Request a prior authorization for a medically necessary EPSDT special service in the event other
health care, diagnostic, preventive or rehabilitative services or treatment or other measures
described in 42 U.S.C. 1396d(a) are not otherwise covered under the Florida Medicaid program
 Monitor, track and follow up with members:
- Who have not had a health assessment screening
- Who miss appointments to assist them in obtaining an appointment
 Ensure members receive the proper referrals to treat any conditions or problems identified during
the health assessment, including tracking, monitoring and following up with members to ensure
they receive the necessary medical services
 Assist members with transition to other appropriate care for children who age-out of EPSDT services
Amerigroup recommends that participating providers who administer immunizations to children under
the age of 18 to utilize the Centers for Disease Control (CDC) Immunization Schedule for Persons Aged
0 through 18. This schedule can be found at http://www.cdc.gov/vaccines/schedules/index.html or
under Appendix A of this manual.
Well-child Visits Reminder Program
Based on Amerigroup claims data, we send a list of members who may not have received wellness
services according to schedule to the members’ PCPs each quarter. Additionally, we mail information
to these members encouraging them to contact their PCPs’ offices to set up appointments for needed
services.
Please note:
 The specific service(s) needed for each member is listed in the report; reports are based only on
services received during the time the member is enrolled with Amerigroup
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


Services must be rendered on or after the due date in accordance with federal EPSDT and state
Department of Health guidelines; in accordance with these guidelines, services received prior to
the specified schedule date do not fulfill EPSDT requirements
This list is generated based on Amerigroup claims data received prior to the date printed on the
list; in some instances, the appropriate services may have been provided after the report run date
To ensure accuracy in tracking preventive services, please submit a completed claim form for those
dates of service to the Amerigroup Claims department at:
Florida Claims
Amerigroup Community Care
P.O. Box 61010
Virginia Beach, VA 23466-1010
Blood Lead Testing Requirements
During every well-child visit for children between the ages of 6 months and 6 years, the PCP should
screen each child for lead poisoning. Amerigroup requires all PCPs to test for high blood lead levels in
accordance with Centers for Medicare & Medicaid Services (CMS) requirements. These requirements
state that all Medicaid enrollees must have a blood lead test performed at 12 months and 24 months
of age to determine lead exposure and toxicity. In addition, children over the age of 24 months, up to
72 months, should receive a blood lead test if there is no past record of a test. Please see blood lead
risk forms located in Appendix A — Forms.
We encourage providers to contact Medtox to receive supplies to test children’s blood lead levels in
their offices. With a simple finger prick and a drop of blood on the filter paper from Medtox, the
member will not have to go to another provider/lab to have the services done. Once you return the
sample by mail, Medtox will send you the results and bill Amerigroup for the test.
For those children who have a blood level greater than or equal to 10, continued testing is required
until the blood level is below 10.
Vaccines for Children for Medicaid Recipients
The VFC program is a federally funded program that provides vaccines at no cost to children who might
not otherwise be vaccinated because of an inability to pay. VFC was created by the Omnibus Budget
Reconciliation Act of 1993 as an entitlement program to be a required part of each state’s Medicaid
plan. The program was officially implemented in October 1994.
Funding for the VFC program is approved by the Office of Management and Budget and allocated
through CMS to the Centers for Disease Control and Prevention (CDC). CDC buys vaccines at a discount
and distributes them to grantees (i.e., state health departments and certain local and territorial public
health agencies) that then distribute them at no charge to those private physicians’ offices and public
health clinics registered as VFC providers.
Children who are eligible for VFC vaccines are entitled to receive pediatric vaccines recommended by
the ACIP.
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Amerigroup requires our providers to participate in the VFC program and have sufficient vaccine
supplies. For additional information on the VFC program, visit cdc.gov/vaccines/
programs/vfc/default.htm.
Family Planning Services
Members have direct access to both network and non-network providers for all family planning
services, including exams, assessments and traditional contraceptive devices. Services are not covered
for members under the age of 18 unless they are married, a parent, pregnant or will suffer health
hazards if services are not provided. FHK coverage of family planning is limited to one annual visit and
one visit for a supplier every 90 days.
Smoking Cessation Program
Amerigroup requires all providers to discuss smoking cessation options with their patients who smoke.
Our Smoking Cessation program is designed to help members find the best way for them to quit
smoking and stay smoke-free. We offer members a variety of resources and services free of
charge. The program has many options to choose from, including:
 Community classes — A listing of classes taught in the community
 Phone counseling — Free phone counseling in which trained health coaches work with members
over the phone to identify a personalized cessation method that focuses on behavior and lifestyle
issues
 Prescription benefits
Resources and Tools
The Florida Quitline is a toll-free telephone-based tobacco use cessation service. Any person living in
Florida who wants to try to quit smoking can use the Quitline. The following services are available
through the Quitline:
 Counseling sessions
 Self-help materials
 Counseling and materials in English and Spanish
 Translation service for other languages
 Pharmacotherapy assistance
 TDD service for the deaf or hard of hearing
Online Resources
 A cravings journal, medicines to help members quit and other resources are available at
smokefree.gov
 Pathways to Freedom for African Americans is online at smokefree.gov
 Guia para Dejar de Fumar is a Spanish resource at smokefree.gov
 The American Lung Association’s Freedom from Smoking Program is offered online at ffsonline.org
 More quitting resources are online at quitnet.com
 Support to quit is offered through quitsmokingsupport.com
 Information about why to quit and how to get help can be found at cancer.gov/cancertopics/
factsheet/tobacco/cessation
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Online Continuing Education for Physicians
Providers can receive continuing education training online through these resources:
 MAHP Oral Health and Tobacco Cessation Educational Program for Primary Care Providers
 Treating Tobacco Use and Dependence through the Wisconsin Medical School
 www.medscape.com
 Tobaccocme.com, which offers programs for general medicine, pediatrics and OB/GYN providers
 www.tobaccofreepatients.com
 Tobacco Cessation Podcasts for Physicians
Printed Resources for Members
We offer the following printed resources you can share with members:
 You Can Quit Smoking flier
 Tobacco Use — Breaking the Habit Ameritip
 Tobacco Use – Reasons to Quit Ameritip
Printed Resources for Providers
 Quick Reference Guide: Treating Tobacco Use and Dependence
All member materials are available on the member website, and provider materials can be accessed
through the provider website.
Audiology Services
Amerigroup provides the following audiology services:
Code/Mod Description
V5090
Dispensing fee, unspecified hearing aid
Comprehensive audiometry threshold evaluation and
92557
speech recognition (92553 and 92556 combined)
92590
Hearing aid examination and selection; monaural
V5011
Fitting/orientation/checking of hearing aid
V5275/RT Ear impression, each — right
V5275/LT Ear impression, each — left
Comprehensive audiometry threshold evaluation and
92557/52 speech recognition (92553 and 92556 combined)
92592
Hearing aid check; monaural
92592/52 Hearing aid recheck; monaural
92552
Pure tone audiometry (threshold); air only
92567
Tympanometry (impedance testing)
Evoked otoacoustic emissions; limited (single stimulus
92587
level, either transient or distortion products)
Comprehensive or diagnostic evaluation (comparison of
transient and/or distortion product otoacoustic emissions
92588
at multiple levels and frequencies)
Auditory evoked potentials for evoked response
audiometry and/or testing of the central nervous system;
92585
comprehensive
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Unit Length
1 handling
Frequency
6 every 12 months
1 evaluation
1 evaluation
1 orientation
1 ear mold
1 ear mold
1 every 12 months
6 every 12 months
6 every 12 months
6 every 12 months
6 every 12 months
1 re-evaluation
1 analysis
1 recheck
1 test
1 test
6 every 12 months
6 every 12 months
6 every 12 months
6 every 12 months
6 every 12 months
1 test
No limit
1 test
No limit
1 test
No limit
Code/Mod Description
Auditory evoked potentials for evoked response
audiometry and/or testing of the central nervous system;
92585/52 comprehensive
92584
Electrocochleography
92626
Evaluation of auditory rehabilitation status; first hour
Unit Length
Frequency
1 test
1 test
1 test
No limit
1 per implant
10 per year
Outpatient Laboratory and Radiology Services
All outpatient laboratory tests should be performed at a network facility outpatient lab or at one of the
Amerigroup preferred network labs (LabCorp or Quest Diagnostics) unless the test is a Clinical
Laboratory Improvement Amendments (CLIA)-approved office test. Visit the CMS website at
cms.hhs.gov for a complete list of approved accreditation organizations under CLIA. MedSolutions
provides diagnostic radiology management services and will precertify CAT scans, MRA, MRI, nuclear
cardiology and PET scans. Contact MedSolutions at 1-888-693-3211 or www.medsolutionsonline.com
for more information.
Pharmacy Services
The Amerigroup pharmacy benefit provides coverage for medically necessary medications from
licensed prescribers for the purpose of saving lives in emergency situations or during short-term illness,
sustaining life in chronic or long-term illness, or limiting the need for hospitalization. Members have
access to most national pharmacy chains and many independent retail pharmacies.
Covered Drugs
The Amerigroup Pharmacy program uses a Preferred Drug List (PDL). This is a list of the preferred drugs
within the most commonly prescribed therapeutic categories. To prescribe medications that do not
appear on the PDL, please contact Pharmacy Services at 1-800-454-3730. Please refer to the PDL on
our website at providers.amerigroup.com/FL.
Prior Authorization Drugs
Providers are strongly encouraged to write prescriptions for preferred products as listed on the PDL. If
a member cannot use a preferred product as a result of a medical condition, providers are required to
contact Amerigroup Pharmacy Services to obtain prior authorization. Prior authorization may be
requested by calling Pharmacy Services at 1-800-454-3730. Providers must be prepared to provide
relevant clinical information regarding the member’s need for a nonpreferred product or a medication
requiring prior authorization. Decisions are based on medical necessity and are determined according
to certain established medical criteria. Examples of medications that require authorization are listed
below. (Note: This list is subject to change.)
Over-The-Counter Drugs
Amerigroup provides coverage of several OTC drugs when accompanied by a prescription. The
following are examples of covered OTC medication classes:
 Analgesics/antipyretics
 Contraceptives
 Antacids
 Cough and cold preparations
 Antibacterials, topical
 Decongestants
 Antidiarrheals
 Laxatives
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Antiemetics
Antifungals, topical
Antifungals, vaginal
Antihistamines
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Pediculocides
Respiratory agents (including spacing devices)
Topical anti-inflammatories
Excluded Drugs
The following drugs are examples of medications that are excluded from the pharmacy benefit:
 Weight control
 Anti-wrinkle agents (e.g., Renova)
 Drugs used for cosmetic reasons or hair growth
 Drugs used for experimental or investigational indication
 Erectile dysfunction drugs to treat impotence
Informed Consent for Psychotherapeutic Medications for Children
Pursuant to F.S.A. 409.912(51), the Agency for Health Care Administration (ACHA) may not pay for a
psychotropic medication prescribed for a child in the Medicaid program without the express and
informed consent of the child’s parent or legal guardian. The physician shall document the consent in
the child’s medical record and provide the pharmacy with a signed attestation of this documentation
with the prescription.
The psychotherapeutic drugs affected are antipsychotics, antidepressants, anti-anxiety medications and
mood stabilizers. Anti-convulsants and ADHD medications (i.e., stimulants and nonstimulants) are not
included at this time. Consent forms are available at ahca.myflorida.com/medicaid/prescribed_drug/
med_resource.shtml.
Behavioral Health Services
Overview
Pursuant to the Amerigroup contract with AHCA and the state MMA plan, Amerigroup will provide
coverage for a full range of behavioral health care services (i.e., treatment for psychiatric and
emotional disorders), including community mental health services and mental health targeted case
management services to all members in contracted counties. Amerigroup will provide coverage of
mental health and alcohol and drug treatment for Florida Healthy Kids members residing in the
counties in which Amerigroup participates as part of the member’s behavioral health benefit.
Primary and Specialty Services
PCPs are encouraged to screen members for behavioral health and alcohol and drug abuse conditions
as a part of the initial assessment or whenever there is a suspicion that a member may have a
behavioral health condition.
A PCP can offer covered behavioral health and/or alcohol and drug abuse services when:
 Services are within the scope of the PCP’s license
 The member’s current condition is not so severe, confounding or complex as to warrant a referral
to a mental health and alcohol and drug abuse provider
 The member is willing to be treated by the PCP
 Services are within the scope of the benefit plan
PCPs are encouraged to educate members with behavioral health and/or alcohol and drug abuse
conditions about the nature of the condition and its treatment. As appropriate, PCPs are also
encouraged to educate members about the relationship between physical and behavioral health and
alcohol and drug abuse conditions.
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Referral for Mental Health and Alcohol and Drug Abuse Conditions
Members may self-refer, or providers may direct members to the Amerigroup network of behavioral
health care providers.
Experienced behavioral health care clinicians are available 24 hours a day, 7 days a week by calling the
Provider Inquiry Line (1-800-454-3730) to assist with identifying the closest and most appropriate
behavioral health service.
Behavioral Health Claims
Paper behavioral health claims can be submitted to the following address:
Amerigroup Community Care
P.O. Box 61010
Virginia Beach, VA 23466-1010
Electronic behavioral health claims may be submitted through the Amerigroup contracted
clearinghouses. To initiate the electronic claims submission process or obtain additional information,
please contact the Amerigroup Electronic Data Interchange (EDI) Hotline at 1-800-590-5745.
Behavioral Health Emergency Services
Behavioral health emergency services are those services that are required to meet the needs of an
individual who is experiencing an acute crisis resulting from a mental illness, which is at a level of
severity that would meet the requirements for involuntary examination pursuant to Section 394.463,
F.S., and who, in the absence of a suitable alternative or psychiatric medication, would require
hospitalization.
Examples of behavioral health and alcohol and drug abuse emergency medical conditions are when:
 The member is suicidal
 The member is homicidal
 The member is violent with objects
 The member has suffered a precipitous decline in functional impairment and is unable to take care
of his or her activities of daily living
 The member is alcohol- or drug-dependent and there are signs of severe withdrawal
In the event of a behavioral health and/or alcohol and drug abuse emergency, the safety of the
member and others is paramount. The member should be instructed to seek immediate attention at an
emergency room or behavioral health and alcohol and drug abuse crisis service facility. An emergency
dispatch service or 911 should be contacted in the event that the member is a danger to self or others
and is unable to go to an emergency setting.
Behavioral Health Medically Necessary Services
Amerigroup defines medically necessary behavioral health services as those that are:
 Reasonably expected to prevent the onset of an illness, condition or disability; reduce or
ameliorate the physical, behavioral or developmental effects of an illness, condition, injury or
disability; and assist the member to achieve or maintain maximum functional capacity in
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performing daily activities, taking into account both the functional capacity of the member and
those functional capacities appropriate for members of the same age
Reasonably expected to provide an accessible and cost-effective course of treatment or site of
service that is equally effective in comparison to other available, appropriate and substantial
alternatives and is no more intrusive or restrictive than necessary
Sufficient in amount, duration and scope to reasonably achieve their purpose as defined in federal law
Of a quality that meet standards of medical practice and/or health care generally accepted at the
time services are rendered
Behavioral Health Coordination of Care
Amerigroup, through its contracted providers and case management services, will be responsible for
the coordination and active provision of continuity of care for all members. Appropriate and timely
sharing of information is essential when the member is receiving psychotropic medications or has a
new or ongoing medical condition. Additionally, if applicable, Amerigroup will coordinate medical and
behavioral health services.
The exchange of medical information facilitates behavioral and medical health care collaboration. For
example, if the PCP obtains the member’s consent via the authorization for release of information
form, the form is completed and sent to the behavioral health care provider. The behavioral health
care provider may use the release, as necessary, for the administration and provision of care.
Amerigroup providers are mandated to utilize the Functional Assessment Rating Scale (FARS) and
Children’s Functional Assessment Rating Scale (CFARS), which are the outcome measures used by the
state of Florida for Medicaid providers. CFARS are administered for patients ages 6 to 17 and FARS are
administered for patients ages 18 and older. FARS/CFARS assessments are required to be completed at
admission, every 6 months after admission (as long as the member remains a patient) and at discharge.
A FARS/CFARS should not be completed for members who (1) only receive a one-time assessment
service and are immediately discharged or (2) are served in medication-only settings. Additionally,
FARS is not required when a member is admitted and discharged from a crisis stabilization unit.
Changes to any other level of service will require administration of the FARS.
Free Training and Certification Websites
Note that only staff with certification should be providing assessment services. Free trainings are
available online:
 CFARS: https://samh-fars.dcf.state.fl.us/cfars/cfars_home.aspx
 FARS: https://samh-fars.dcf.state.fl.us/fars/fars_home.aspx
The behavioral health care provider should note contacts and collaboration efforts in the member’s
chart as well as determine whether referral assistance is needed for the member for noncovered
services.
When the member has seen a behavioral health care provider, that provider should send a copy of a
completed coordination of care and treatment summary form to both Amerigroup and the member’s
PCP. This form is available on our website at providers.amerigroup.com/FL.
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If a PCP refers a member to a contracted behavioral health care provider, the PCP will fax a copy of a
completed coordination of care and treatment summary form to the designated behavioral health care
fax number at 1-800-505-1193 and to the behavioral health care provider.
The behavioral health care provider will send initial and quarterly (or more frequently if clinically
indicated) summary reports of the member’s behavioral health status to the member’s PCP. The PCP
will be contacted if there is a change in the behavioral health treatment plan. The PCP will contact the
behavioral health care provider and document the information on the coordination of care and
treatment summary form if the member’s medical condition could reasonably be expected to affect
the member’s mental health treatment planning or outcome.
Self-referral Services
The following services do not need a referral from a PCP:
 Emergent care (regardless of network status with Amerigroup)
 Family planning (regardless of network status with Amerigroup)
 Behavioral health assessments (nonparticipating providers must seek prior approval from
Amerigroup)
 OB care (nonparticipating providers must seek prior approval from Amerigroup)
 Well-woman/GYN care (nonparticipating providers must seek prior approval from Amerigroup)
 EPSDT/Well-child services (nonparticipating providers must seek prior approval from Amerigroup)
 Tuberculosis, STD, HIV/AIDS testing and counseling services (regardless of network status with
Amerigroup)
Member Rights and Responsibilities
Florida law requires that providers or health care facilities recognize the rights of members while they
are receiving medical care and that members respect the health care provider’s or health care facility’s
right to expect certain behavior on the part of members. Members may request a copy of the full text
of this law from their health care provider or health care facility. The following is a summary of the
member’s rights and responsibilities. See Section 381.026, Florida Statutes
Patients’ Rights
Patients have a right to:
 Be treated with respect and with due consideration for dignity and privacy
 A prompt and reasonable response to questions and requests
 Know who is providing medical services and who is responsible for their care; know what member
support services are available, including whether an interpreter is available if they don’t speak
English
 Know what rules and regulations apply to their conduct
 Receive information on available treatment options and alternatives, presented in a manner
appropriate to their conditions and ability to understand; members are given the opportunity to be
involved in decisions involving their health care, except when such participation is contraindicated
(not recommended) for medical reasons
 Participate in decisions regarding their health care, including the right to refuse treatment
 Be given health care services in line with federal and state regulations
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Be given, upon request, full information and necessary advice of available financial help for their
care
Receive, upon request, before treatment, a reasonable estimate of charges for medical care
Receive a copy of a reasonably clear and easy-to-understand itemized bill and, upon request, to
have the charges explained
Impartial access to medical treatment or accommodations, no matter of race, national origin,
religion, physical handicap or source of payment
Treatment for any emergency medical condition that will get worse from not getting the proper
treatment
Know if medical treatment is for experimental research and to give your or refusal to be involved in
that research
File grievances regarding any violation of their rights, as states in Florida law, through the grievance
procedure to the health care provider or health care facility that served them and to the
appropriate state licensing agency
Be free from any form of restraint (control) or seclusion used as coercion (force), discipline,
convenience or retaliation (revenge)
Ask for and get a copy of their medical records and ask that those records be updated or corrected
Also, the state must make sure you’re able to use your rights and those rights do not change the way
Amerigroup and its providers or the state agency treat you
Patients’ Responsibilities
Patients have the responsibility to:
 Provide their health care provider, to the best of their knowledge, correct and complete
information about present complaints, past illnesses, hospitalizations, medications (including overthe-counter products), dietary supplements, any allergies or sensitivities, and other matters
relating to their health
 Report unexpected changes in their conditions to their health care providers
 Report to their health care providers whether they understand a planned action and what is
expected of them
 Follow the treatment plan recommended by the health care provider
 Keep appointments and, when not able to for any reason, tell the health care provider or health
care facility
 Understand their actions if they refuse treatment or don’t follow the health care provider’s
instructions
 Inform their providers about any living wills, medical powers of attorney or other directives that
could change their care
 Make sure the needs of their health care are met as quickly as possible
 Follow health care facility rules and regulations about member care and conduct
 Behave in a way that is respectful of all health care providers and staff, as well as of other members
First Line of Defense Against Fraud
General Obligation to Prevent, Detect and Deter Fraud, Waste and Abuse
As a recipient of funds from state and federally sponsored health care programs, we each have a duty
to help prevent, detect and deter fraud, waste and abuse. Amerigroup commitment to detecting,
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mitigating and preventing fraud, waste and abuse is outlined in our Corporate Compliance Program. As
part of the requirements of the federal Deficit Reduction Act, each Amerigroup provider is required to
adopt Amerigroup policies on detecting, preventing and mitigating fraud, waste and abuse in all the
federally and state-funded health care programs in which Amerigroup participates.
Amerigroup policy on fraud, waste and abuse prevention and detection is part of the Amerigroup
Corporate Compliance Program. Electronic copies of this policy and the Amerigroup Code of Business
Conduct and Ethics are available at amerigroup.com/about-amerigroup/ethics.
Amerigroup maintains several ways to report suspected fraud, waste and abuse. As an Amerigroup
provider and a participant in government-sponsored health care, you and your staff are obligated to
report suspected fraud, waste and abuse. These reports can be made anonymously online at
amerigroup.silentwhistle.com. In addition to anonymous reporting, suspected fraud, waste and abuse
may also be sent via email to [email protected] Suspected fraud may also be reported by
calling Amerigroup Customer Service at 1-800-600-4441 or reaching out directly to the Amerigroup
Chief Compliance Officer (CCO) at 757-473-2711 or via email to [email protected]
To report suspected fraud or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll free
at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available online
at apps.ahca.myflorida.com/inspectorgeneral/fraud_complaintform.aspx. If you report suspected
fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health
care provider, you may be eligible for a reward through the Inspector General’s Fraud Rewards
Program. You can call the Inspector General’s office at 850-414-3990 or toll free at 1-866-866-7226.
The reward may be up to 25 percent of the amount recovered or a maximum of $500,000 per case
(Florida Statutes Chapter 409.9203). You can talk to the Attorney General’s office about keeping your
identity confidential and protected.
In order to meet the requirements under the Deficit Reduction Act, you must adopt the Amerigroup
fraud, waste and abuse policies and distribute them to any staff member or contractor who works with
Amerigroup. If you have questions or would like to have more details concerning the Amerigroup fraud,
waste and abuse detection, prevention and mitigation program, please contact the Amerigroup CCO.
Importance of Detecting, Deterring and Preventing Fraud, Waste and Abuse
Health care fraud costs taxpayers increasingly more money every year. There are state and federal
laws designed to crack down on these crimes and impose strict penalties. Fraud, waste and abuse in
the health care industry may be perpetuated by every party involved in the health care process. There
are several stages to inhibiting fraudulent acts, including detection, prevention, investigation and
reporting. In this section, we educate providers on how to help prevent member and provider fraud by
identifying the different types so you can be the first line of defense.
Many types of fraud, waste and abuse have been identified, including the following:
Provider Fraud, Waste and Abuse
 Billing for services not rendered
 Billing for services that were not medically necessary
 Double billing
 Unbundling
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 Upcoding
Providers can help prevent fraud, waste and abuse by ensuring that the services rendered are
medically necessary, accurately documented in the medical records and billed according to American
Medical Association guidelines.
Member Fraud, Waste and Abuse
 Benefit sharing
 Collusion
 Drug trafficking
 Forgery
 Illicit drug seeking
 Impersonation fraud
 Misinformation and/or misrepresentation
 Subrogation and/or third-party liability fraud
 Transportation fraud
To help prevent fraud, waste and abuse, providers can educate members about the types of fraud and
the penalties levied. Also, spending time with patients and reviewing their records for prescription
administration will help minimize drug fraud and abuse. One of the most important steps to help prevent
member fraud is as simple as reviewing the Amerigroup member ID card. It is the first line of defense
against fraud. Amerigroup may not accept responsibility for the costs incurred by providers rendering
services to a patient who is not a member even if that patient presents an Amerigroup member ID.
Providers should take measure to ensure the cardholder is the person named on the card.
Additionally, encourage members to protect their cards as they would a credit card or cash, carry their
Amerigroup member ID at all times, and report any lost or stolen cards to Amerigroup as soon as possible.
Amerigroup believes that awareness and action are vital to keeping the state and federal programs
safe and effective. Understanding the various opportunities for fraud, waste or abuse and working with
members to protect their Amerigroup ID cards can help prevent fraud, waste and abuse. We
encourage our members and providers to report any suspected instance of fraud, waste or abuse by
calling Customer Service at 1-800-600-4441, emailing [email protected] or contacting the
Amerigroup Chief Compliance Officer. An anonymous report also can be made by visiting
amerigroup.silentwhistle.com. No individual who reports violations or suspected fraud, waste or abuse
will be retaliated against, and Amerigroup will make every effort to maintain anonymity and
confidentiality.
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA, also known as the Kennedy-Kassebaum
bill) was signed into law in August 1996. The legislation improves the portability and continuity of
health benefits, ensures greater accountability in the area of health care fraud and simplifies the
administration of health insurance.
Amerigroup strives to ensure that both Amerigroup and contracted providers conduct business in a
manner that safeguards patient/member information in accordance with the privacy regulations
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enacted pursuant to HIPAA. Contracted providers must have the following procedures implemented to
demonstrate compliance with the HIPAA privacy regulations.
We recognize our responsibility under the HIPAA privacy regulations to only request the minimum
necessary member information from providers to accomplish the intended purpose. Conversely,
network providers should only request the minimum necessary member information required to
accomplish the intended purpose when contacting Amerigroup. However, please note that the privacy
regulations allow the transfer or sharing of member information, which may be requested by
Amerigroup to conduct business and make decisions about care, such as a member’s medical record,
to make an authorization determination or resolve a payment appeal. Such requests are considered
part of the HIPAA definition of treatment, payment or health care operations.
Fax machines used to transmit and receive medically sensitive information should be maintained in an
environment with restricted access to individuals who need member information to perform their jobs.
When faxing information to Amerigroup, verify that the receiving fax number is correct, notify the
appropriate staff at Amerigroup and verify that the fax was appropriately received.
Email (unless encrypted) should not be used to transfer files containing member information to
Amerigroup (e.g., Excel spreadsheets with claim information). Such information should be mailed or
faxed.
Please use professional judgment when mailing medically sensitive information such as medical
records. The information should be in a sealed envelope marked confidential and addressed to a
specific individual, post office box or department at Amerigroup.
The Amerigroup voicemail system is secure and password-protected. When leaving messages for
Amerigroup associates, only leave the minimum amount of member information required to
accomplish the intended purpose.
When contacting Amerigroup, please be prepared to verify the provider’s name, address and tax
identification number, national provider identifier or Amerigroup provider ID.
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MEMBER MANAGEMENT SUPPORT
Welcome Call
As part of our member management strategy, Amerigroup offers a welcome call to new members.
During the welcome call, new members who have been identified through their health risk assessment
as possibly needing additional services are educated regarding the health plan and available services.
Additionally, Member Services representatives offer to assist the member with any current needs such
as scheduling an initial checkup.
Appointment Scheduling
Amerigroup, through our participating providers, ensures that members have access to primary care
services for routine, urgent and emergency services and to specialty care services for chronic and
complex care. Providers will respond to an Amerigroup member’s needs and requests in a timely
manner. The Primary Care Provider (PCP) should make every effort to schedule Amerigroup members
for appointments using the guidelines outlined in the PCP Access and Availability section.
Nurse HelpLine
The Amerigroup Nurse HelpLine is a service designed to support the provider by offering information
and education about medical conditions, health care and prevention to members after normal
physician practice hours. The Nurse HelpLine provides triage services and helps direct members to
appropriate levels of care. The Amerigroup Nurse HelpLine telephone number is 1-866-864-2544
(English)/1-866-864-2545 (Spanish) and is listed on the member’s ID card. This ensures that members
have an additional avenue of access to health care information when needed. Features of the Nurse
HelpLine include:
 Availability 24 hours a day, 7 days a week
 Information based upon nationally recognized and accepted guidelines
 Free translation services for 150 different languages and for members that are deaf or hard of
hearing
 Education for members regarding appropriate alternatives for handling nonemergent medical
conditions
 Faxing of the member’s assessment report by a nurse to the provider’s office within 24 hours of
receipt of a call
Interpreter Services
Interpreter services are available if needed. Contact the Amerigroup Provider Services department at
the National Customer Care department at 1-800-454-3730.
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Health Promotion
Amerigroup strives to improve healthy behaviors, reduce illness and improve the quality of life for our
members through comprehensive programs. Educational materials are developed or purchased and
disseminated to our members, and health education classes are available through Amerigroupcontracted community organizations and network providers that are contracted with Amerigroup.
Amerigroup manages projects that offer our members education and information regarding their
health. Ongoing projects include:
 A newsletter to members at least once a year
 Creation and distribution of Ameritips, an Amerigroup health education tool used to inform
members of health promotion issues and topics
 Health Tips on Hold, which are educational telephone messages that play while the member is on
hold
 A monthly calendar of health education programs offered to members
 Development of health education curricula and procurement of other health education tools (e.g.,
breast self-exam cards)
 Relationship development with community-based organizations to enhance opportunities for
members
 Available community resources via the Amerigroup website at www.myamerigroup.com/FL
Case Management
Case Management is designed to proactively respond to a member’s needs when conditions or
diagnoses require care and treatment for long periods of time. When a member is identified (usually
through precertification, admission review, and/or provider or member request), the Amerigroup
nurse helps to identify medically appropriate alternative methods or settings in which care may be
delivered.
A provider, on behalf of the member, may request participation in the program. The clinician will work
with the member, provider and/or the hospital to identify the necessary:
 Intensity level of case management services needed
 Appropriate alternate settings where care may be delivered
 Health care services required
 Equipment and/or supplies required
 Community-based services available
 Communication required (i.e., between the member and PCP)
The Amerigroup clinician will assist the member, utilization review team, and PCP and/or hospital in
developing the discharge plan of care, ensuring that the member’s medical needs are met, and linking
the member with community resources and Amerigroup programs for outpatient case and/or disease
management.
Please note, an Amerigroup case manager cannot perform services that are limited to providers such
as overriding the need to prior authorize prescription medications.
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Disease Management Centralized Care Unit
Disease Management Centralized Care Unit (DMCCU) programs are based on a system of coordinated
care management interventions and communications designed to assist physicians and others in
managing members with chronic conditions. The programs include a holistic, member-centric care
management approach that allows care managers to focus on multiple needs of members.
Disease Management (DM) programs include but are not limited to:
 Behavioral health
 Diabetes
- Bipolar disorder
 HIV/AIDS
- Schizophrenia
 Pulmonary
 Cardiac
- Asthma
- Coronary artery disease
- Chronic obstructive pulmonary disease
- Congestive heart failure
Additional DM programs may be available for members in your area. Please call the number provided
to learn if these programs apply to your members:
 Hypertension
 Bipolar disorder
 Obesity
Program Features
 Uses proactive population identification processes
 Based on evidence-based national practice guidelines
 Based on collaborative practice models to include physician and support-service providers in
treatment planning for members
 Offers continuous patient self-management education, including primary prevention, behavior
modification programs and compliance/surveillance, as well as home visits and case/care
management for high-risk members
 Offers ongoing process and outcomes measurement, evaluation and management
 Offers ongoing communication with providers regarding patient status
Amerigroup DM programs are based on nationally approved clinical practice guidelines located at
providers.amerigroup.com/FL. Simply access the Florida website and log in to the secure site by
entering your login name and password. At the top of the page, select Clinical Policy & Guidelines and
then Clinical Practice Guidelines. A copy of the guidelines can be printed from the website, or you can
contact Provider Services at 1-800-454-3730 to receive a printed copy.
Who is Eligible?
All members with the above conditions/diagnoses are eligible for DMCCU services. Members are
identified through continuous case finding efforts that include but are not limited to continuous case
finding, welcome calls, claims mining and referrals.
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DMCCU Provider Rights and Responsibilities
The provider has the right to:
 Have information about Amerigroup, including provided programs and services, our staff, and our
staff’s qualifications and any contractual relationships
 Decline to participate in or work with the Amerigroup programs and services for his or her patients,
depending on contractual requirements
 Be informed of how Amerigroup coordinates our interventions with treatment plans for individual
patients
 Know how to contact the person responsible for managing and communicating with the provider’s
patients
 Be supported by the organization to make decisions interactively with patients regarding their
health care
 Receive courteous and respectful treatment from Amerigroup staff
 Communicate complaints regarding DMCCU as outlined in the Amerigroup Provider Complaint and
Grievance Procedure
Hours of Operation
Amerigroup care managers are licensed nurses/social workers and are available from 8:30 a.m. to 5:30
p.m. Eastern time, Monday through Friday. Confidential voicemail is available 24 hours a day.
Contact Information
Please call 1-888-830-4300 to reach a care manager. Additional information about disease
management can be obtained by visiting providers.amerigroup.com/FL. Select Patient & Medical
Support and then click on the link for Disease Management (DMCCU). Members can obtain
information about our DMCCU by visiting www.myamerigroup.com or calling 1-888-830-4300.
Health Education Advisory Committee
The Health Education Advisory Committee provides advice to Amerigroup regarding health education
and outreach program development. The Committee strives to ensure that materials and programs
meet cultural competency requirements and are both understandable to the member and address the
member’s health education needs.
The Health Education Advisory Committee’s responsibilities are to:
 Identify health education needs of the membership based on review of demographic and
epidemiologic data
 Assist the health plan in decision-making in the areas of member grievances, marketing, member
services, case management, outreach, health needs and cultural competency
 Identify cultural values and beliefs that must be considered in developing a culturally competent
health education program
 Assist in the review, development, implementation and evaluation of the member health education
tools for the outreach program
 Review the health education plan and make recommendations on health education strategies
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WIC Program
The Women, Infants and Children (WIC) program impacts the health of mothers and children in the
medically needy population. Optimal nutritional status during pregnancy and early childhood provides
the best chance for the future of Floridians.
Medicaid recipients eligible for WIC benefits include the following classifications:
 Pregnant women
 Women who are breast-feeding infant(s) up to one year postpartum
 Women who are not breast-feeding up to six months postpartum
 Infants under the age of 1
 Children under the age of 5
Network providers are expected to coordinate with the WIC program. Coordination includes referral to
the local WIC office for all infants and children up to age 5 and pregnant, breast-feeding and
postpartum women.
WIC Referrals
Amerigroup providers are required to refer all infants and children up to age 5 and pregnant,
breast-feeding and postpartum women to the local WIC office. Providers are required to send WIC:
 A completed Florida WIC program medical referral form (located in the form section of Appendix A)
with the current height or length and weight (taken within 60 calendar days of the WIC
appointment)
 Hemoglobin or hematocrit
 Any identified medical and/or nutritional problems
For each subsequent WIC certification, providers are required to coordinate with the local WIC office
to provide the above referral data from the most recent Child Health Check-Up (CHCUP). Each time you
complete the WIC referral form, providers are required to give a copy to the enrollee and keep a copy
in the patient’s medical record.
Members may apply for WIC services at their local WIC agency service. Please call Provider Services at
1-800-454-3730 for the agency nearest to the member. For more information, please visit
doh.state.fl.us/family/wic.
Pregnancy-related Requirements
Prenatal Risk Screening
Providers seeing Amerigroup members for pregnancy-related diagnoses must:
 See the pregnant member within 30 days of enrollment
 Complete Florida’s Healthy Start prenatal risk screening to each pregnant member as part of her
first prenatal visit as required by Section 383.14, F.S., Section 381.004, F.S., and 64C-7.009, F.A.C.
- Use the Department of Health prenatal risk form (DH Form 3134), which can be obtained from
the local County Health Department (CHD)
- Retain a copy of all documentation of Healthy Start screenings, assessments, findings and
referrals in the enrollees’ medical records
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Submit the completed DH Form 3134 to the CHD in the county in which the prenatal screen was
completed within 10 business days of completion
Collaborate with the Healthy Start care coordinator within the member’s county of residence to
assure risk-appropriate care is delivered
Pregnant members or infants who do not score high enough to be eligible for Healthy Start care
coordination may be referred for services, regardless of their score on the Healthy Start risk screen,
in the following ways:
- If the referral is to be made at the same time the Healthy Start risk screen is administered, the
provider may indicate on the risk screening form that the member or infant is invited to
participate based on factors other than score
- If the determination is made subsequent to risk screening, the provider may refer the enrollee
or infant directly to the Healthy Start care coordinator based on assessment of actual or
potential factors associated with high risk, such as HIV, hepatitis B, substance abuse or
domestic violence
Infant Risk Screening
Providers must complete the Florida Healthy Start infant (postnatal) risk screening instrument (DH
Form 3135) with the certificate of live birth and transmit the documents to the CHD in the county in
which the infant was born within 10 business days of the birth. Providers must retain a copy of the
completed DH Form 3135 in the patient’s medical record and provide a copy to the patient.
HIV Testing
Providers are required to give all women of childbearing age HIV counseling and offer them HIV
testing. See Chapter 381, F.S.
 Providers, in accordance with Florida law, must offer all pregnant women counseling and HIV
testing at the initial prenatal care visit and again at 28 to 32 weeks of pregnancy
 Providers must attempt to obtain a signed objection if a pregnant woman declines an HIV test. See
Section 384.31, F.S. and 64D-3.019, F.A.C.
 For those women who are infected with HIV, providers are to offer and provide counseling about
the latest antiretroviral regimen recommended by the U.S. Department of Health & Human
Services (per the U.S. Department of Health & Human Services, Public Health Service Task Force
Report titled Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected
Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the
United States; to receive a copy of the guidelines, contact the Department of Health, Bureau of
HIV/AIDS, at 850-245-4334 or visit aidsinfo.nih.gov/guidelines)
Hepatitis B Screenings
Providers are required to:
 Screen all pregnant members receiving prenatal care for the Hepatitis B surface antigen (HBsAg)
during the first prenatal visit
 Perform a second HBsAg test between 28 and 32 weeks of pregnancy for all pregnant members who
tested negative at the first prenatal visit and are considered high-risk for Hepatitis B infection; this
test shall be performed at the same time that the other routine prenatal screenings are ordered
 Report all HBsAg-positive women to the local CHD and to Healthy Start, regardless of their Healthy
Start screening score
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Hepatitis B and Hepatitis B Immune Globulin Vaccines
 Infants born to HBsAg-positive members must receive Hepatitis B immune globulin and the
Hepatitis B vaccine once they are physiologically stable, preferably within 12 hours of birth, and
complete the Hepatitis B Maxine vaccine series according to the recommended vaccine schedule
established by the Recommended Childhood Immunization Schedule for the United States
 Providers must test infants born to HBsAg-positive members for HBsAg and Hepatitis B surface
antibodies (anti-HBs) six months after the completion of the vaccine series to monitor the success
or failure of the therapy
 Providers must report to the local CHD a positive HBsAg result in any child 24 months or younger
within 24 hours of receipt of the positive test results
 Providers must refer infants born to members who are HBsAg-positive to Healthy Start regardless
of their Healthy Start screening scores
Testing Positive for Hepatitis B
Providers are required to:
 Report to the perinatal Hepatitis B prevention coordinator at the local CHD all prenatal or
postpartum patients who test HBsAg-positive
 Report said patients’ infants and contacts to the perinatal Hepatitis B prevention coordinator at the
local CHD
 Report the following information: name, date of birth, race, ethnicity, address, infants, contacts,
laboratory test performed, date the sample was collected, the due date or EDC, whether or not the
enrollee received prenatal care, and immunization dates for infants and contacts
 Use the perinatal Hepatitis B case and contact report (DH Form 1876) for reporting purposes
Providers are required to provide the most appropriate and highest level of quality care for pregnant
members, including but not limited to the following:
 Prenatal care
- Complete a pregnancy test and a nursing assessment with referrals to a physician, physician
assistant or advanced registered nurse practitioner for comprehensive evaluation
- Complete case management through the gestational period according to the needs of the member
- Ensure any necessary referrals and follow-up
- Schedule return prenatal visits at least every four weeks until week 32, every two weeks until
week 36 and every week thereafter until delivery unless the member’s condition requires more
frequent visits
- Contact those members who fail to keep their prenatal appointments as soon as possible and
arrange for their continued prenatal care
- Assist members in making delivery arrangements if necessary
- Screen all pregnant members for tobacco use and make available to pregnant members
smoking cessation counseling and appropriate treatment as needed
 Nutritional assessment/counseling — Providers are required to:
- Supply nutritional assessment and counseling to all pregnant members:
- Ensure the provision of safe and adequate nutrition for infants by promoting breast-feeding
and the use of breast milk substitutes
- Offer a mid-level nutrition assessment
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Provide individualized diet counseling and a nutrition care plan by a public health nutritionist, a
nurse or a physician following the nutrition assessment
- Keep documentation of the nutrition care plan in the medical record by the person providing
counseling
Obstetrical delivery — Amerigroup has developed and uses generally accepted and approved
protocols for both low-risk and high-risk deliveries, which reflect the highest standards of the
medical profession, including Healthy Start and prenatal screening; and requires all providers use
these protocols:
- Providers must document preterm delivery risk assessments in the enrollee’s medical record by
the 28th week
- If the provider determines that the member’s pregnancy is high-risk, the provider’s obstetrical
care during labor and delivery must include preparation by all attendants for symptomatic
evaluation and as the member progresses through the final stages of labor and immediate
postpartum care
Newborn care — Providers are required to supply the highest level of care for the newborn
beginning immediately after birth. Such level of care shall include but not be limited to the
following:
- Instilling prophylactic eye medications into each eye of the newborn
- When the mother is Rh-negative, securing a cord blood sample for type Rh determination and
direct Coombs testing
- Weighing and measuring the newborn
- Examining the newborn for abnormalities and/or complications
- Administering 0.5 mg of vitamin K
- Calculating an Apgar score
- Assessing any other necessary and immediate need for referral in consultation with a specialty
physician, such as the Healthy Start (postnatal) infant screen
- Administering any necessary newborn and infant hearing screenings, must be conducted by a
licensed audiologist pursuant to Chapter 468, F.S.; a physician licensed under Chapters 458 or
459, F.S.; or an individual who has completed documented training specifically for newborn
hearing screenings and who is directly or indirectly supervised by a licensed physician or a
licensed audiologist
Postpartum care — The provider is required to:
- Administer a postpartum examination for the member between 21 and 56 days post delivery
- Supply voluntary family planning, including a discussion of all methods of contraception as
appropriate
- Ensure eligible newborns are enrolled with Amerigroup and that continuing care of the
newborn is provided through the CHCUP program component
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Healthy Start Program
Healthy Start is a national program that provides comprehensive developmental services for pregnant
women, infants and preschool children ages 3 to 5. We collaborate with community Healthy Start
programs to provide timely and age-appropriate health screening and referrals for routine health
services.
 Amerigroup provides each member with a community-based PCP
 Amerigroup encourages Healthy Start staff to refer members to see their PCP for screenings and
health services
 Amerigroup supports timely and complete immunization of all children
 Amerigroup supports routine dental, vision and hearing exams for members
 Amerigroup encourages physical exams in accordance with the CHCUP periodicity schedule
 Amerigroup supports personal hygiene as part of the child’s daily routine through age-appropriate
educational programs
 The Amerigroup Member Services staff, nurse case managers and Health Promotion staff
coordinate the delivery of services for children and work with their caretakers to eliminate barriers
to timely health care
Local Health Department
Amerigroup work collaboratively with local health departments. Members have access to any county
health department without authorization for the following services:
 Diagnosis and treatment of sexually transmitted diseases and other communicable diseases, such
as tuberculosis and HIV
 Immunizations
 Family planning services and related pharmaceuticals
 School health services listed above and services rendered on an urgent basis by such providers
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PROVIDER RESPONSIBILITIES
Medical Home
The PCP is the foundation of the medical home, responsible for providing, managing and coordinating
all aspects of the member’s medical care and providing all care that is within the scope of his or her
practice. The PCP is responsible for coordinating member care with specialists and conferring and
collaborating with the specialists, using a collaborative concept known as a medical home.
Amerigroup promotes the medical home concept to all of its members. The PCP is the member and
family’s initial contact point when accessing health care. The PCP relationship with the member and
family, together with the health care providers within the medical home and the extended network of
consultants and specialists with whom the medical home works, have an ongoing and collaborative
contractual relationship. The providers in the medical home are knowledgeable about the member and
family’s special and health-related social and educational needs and are connected to necessary
resources in the community that will assist the family in meeting those needs. When a member is
referred for a consultation or specialty/hospital services or for health and health-related services by
the PCP through the medical home, the medical home provider maintains the primary relationship
with the member and family. He or she keeps abreast of the current status of the member and family
through a planned feedback mechanism with the PCP who receives them into the medical home for
continuing primary medical care and preventive health services.
Providers’ Bill of Rights
Each health care provider who contracts with the Florida Agency for Health Care Administration
(AHCA) and/or Florida Healthy Kids or subcontracts with Amerigroup to furnish services to members
will be assured of the following rights:
 To advise or advocate (within the lawful scope of practice) on behalf of a member who is his or her
patient, for the following:
- The member’s health status, medical care or treatment options, including any alternative
treatment that may be self-administered
- Any information the member needs in order to decide among all relevant treatment options
- The risks, benefits and consequences of treatment or nontreatment
- The member’s right to participate in decisions regarding his or her health care, including the
right to refuse treatment and to express preferences about future treatment decisions
 To receive information on the grievance, appeal and fair hearing procedures
 To have access to the Amerigroup policies and procedures covering the authorization of services
 To be notified of any decision by Amerigroup to deny a service authorization request or to
authorize a service in an amount, duration or scope that is less than requested
 To challenge, on behalf of Medicaid members, the denial of coverage of or payment for medical assistance
 To be free from provider selection policies and procedures that discriminate against particular
providers that serve high-risk populations or specialize in conditions that require costly treatment
 To be free from discrimination for participation, reimbursement or indemnification when acting
within the scope of his or her license or certification under applicable state law, solely on the basis
of that license or certification
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Responsibilities of the PCP
The PCP is a network physician who has responsibility for the complete care of his or her members, whether
providing it himself or herself or by referral to the appropriate provider of care within the network. FQHCs
health and RHCs may be included as PCPs. Some of the PCP’s responsibilities are listed below:
 All Florida Healthy Kids PCPs must be board-certified pediatricians or family practice physicians.
 All PCPs must provide coverage 24 hours a day, 7 days a week, and regular hours of operation must
be clearly defined and communicated to members.
 All PCPs must provide services ethically and legally in a culturally competent manner and meet the
unique needs of members with special health care requirements.
 The PCP is the coordinator of all care. Therefore, the PCP agrees to ensure continuity of care to
Amerigroup members and arrange for the provision of services when the PCP’s office is not open.
Documentation of emergency room visits, hospital discharge summaries or operative reports are to
be obtained by the PCP and maintained in the medical record.
 The PCP agrees to practice in his or her profession ethically and legally, provide all services in a
culturally competent manner, accommodate those with disabilities, and not discriminate against
anyone based on his or her health status.
 The PCP must conduct a health assessment of all new enrollees within 90 days of the effective date
of enrollment.
 When clinically indicated, the PCP agrees to contact Amerigroup members regarding appropriate
follow-up of identified problems and abnormal laboratory, radiological or other diagnostic findings.
 The PCP must establish office procedures to facilitate the follow-up of member referrals and
consultations. The PCP is responsible for obtaining and maintaining in the medical record the
results or findings of consultant referrals. If findings were communicated through telephonic
consultation, a summary of the findings and name of the specialist must be documented.
 The PCP must participate in any system established by Amerigroup to facilitate the sharing of
medical records (subject to applicable confidentiality requirements in accordance with 42 CFR, Part
431, Subpart F, including a minor’s consultation, examination and drugs for STDs in accordance
with Section 384.30 (2), F.S.).
 The PCP agrees, when the need arises, to contact Amerigroup regarding interpretive services via
AT&T or other service for members who may require language assistance.
 If a new PCP is added to a group, Amerigroup must approve and credential the provider before the
provider may treat members. Notification of changes in the provider staff is the responsibility of
the provider’s office and must be communicated to Amerigroup in writing.
 The PCP agrees to participate and cooperate with Amerigroup in quality management, utilization
review, continuing education and other similar programs established by Amerigroup.
 The PCP agrees to participate in and cooperate with the Amerigroup grievance and appeal
procedures when Amerigroup notifies the PCP of any member complaints or grievances.
 Balance billing for a covered service is not permitted. A member can only be billed for applicable
copayments if the copayment was not collected at the time the service was rendered.
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In the event that a PCP agreement with Amerigroup is terminated, the PCP must continue care in
progress during and after the termination period for up to six months until a provision is made by
Amerigroup for the reassignment of members. Pregnant members can continue receiving services
through postpartum care. Payment for covered services under this continuity of care period will be
made in accordance with the rates effective in the provider’s participating agreement at the time
of termination.
The PCP may opt to go bare but must follow the requirements under the Florida Statute 458.320.
The PCP must comply with all applicable federal and state laws regarding the confidentiality of
member records
The PCP must certify to Amerigroup whether his or her active member load exceeds 3,000 during
the recredentialing process.
The PCP agrees to develop and have an exposure control plan in compliance with Occupational
Safety and Health Administration (OSHA) standards regarding blood-borne pathogens.
The PCP agrees to establish appropriate policies and procedures to fulfill obligations under the
Americans with Disabilities Act (ADA).
The PCP agrees to support and cooperate with the Amerigroup Quality Management Program to
provide quality care in a responsible and cost-effective manner.
The PCP agrees to provide HIV counseling and offer HIV testing to all members of childbearing age.
The PCP agrees to refer pregnant women or infants to Healthy Start and WIC Children programs
within 30 days of enrollment.
The PCP agrees to provide counseling and education in support of Medicaid quality and benefit
enhancement (QBE) services, which include children’s programs, domestic violence, pregnancy
prevention (including abstinence), prenatal/postpartum care, smoking cessation and substance
abuse programs. The PCP agrees to include information on the programs and community resources
encouraged by Amerigroup.
The PCP agrees to provide counseling and offer the recommended antiretroviral regimen to all
pregnant women who are HIV-positive and to refer them and their infants to Healthy Start
programs, regardless of their screening scores.
The PCP agrees to offer screening for Hepatitis B surface antigen to all women receiving prenatal
care. If they test positive, the PCP agrees to refer them to Healthy Start regardless of their
screening score and to provide Hepatitis B Immune Globulin and the Hepatitis B vaccine series to
children born to such mothers.
The PCP agrees to inform Amerigroup if he or she objects to the provision of any counseling,
treatments or referral services on religious grounds.
The PCP agrees to treat all members with respect and dignity, provide them with appropriate
privacy, and treat members’ disclosures and records confidentially, giving members the
opportunity to approve or refuse their release in accordance with HIPAA and applicable state laws.
The PCP agrees to provide members with complete information concerning their diagnosis,
evaluation, treatment and prognosis and give members the opportunity to participate in decisions
involving their health care, regardless of whether members have completed an advance directive,
except when contraindicated for medical reasons.
The PCP agrees to an adequate and timely communication among providers and the transfer of
information when members are transferred to other health care providers. The PCP agrees to
obtain a signed and dated release allowing for the release of information to Amerigroup and other
providers involved in the member’s care.
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The PCP agrees to physically screen members taken into the protective custody, emergency shelter
or foster care programs by the Department of Children and Families (DCF) within 72 hours or
immediately if required.
The PCP must ensure food snacks or services provided to members meet their clinical needs and
are prepared, stored, secured and disposed of in compliance with local health department
requirements.
The PCP agrees that provisions will be made to minimize sources and transmission of infection in
the office.
The PCP agrees to maintain communication with the appropriate agencies such as local police,
social services agencies and poison control centers to provide quality member care.
The PCP agrees that any notation in a member’s clinical record indicating diagnostic or therapeutic
intervention as part of clinical research will be clearly contrasted with entries regarding the
provision of nonresearch-related care.
The PCP is required to participate with Florida’s Immunization Registry (SHOTS).
The PCP agrees to provide immunization information to the DCF upon receipt of members’ written
permission and DCF’s request for members requesting temporary cash assistance from the DCF.
The PCP agrees to attempt to obtain medical records on any member(s) receiving services from a
non-network provider with the proper release specific to any diagnosis signed by the member.
These services include, but are not limited to, family planning, preventive services and sexually
transmitted diseases.
The PCP agrees to maintain vaccines safely and in accordance with specific guidelines, to provide
member immunizations according to professional standards, and to maintain up-to-date member
immunization records.
The PCP for MediKids members must bill Amerigroup for reimbursement of the vaccine
administration fee on the administration code(s). The PCP must also bill the serum code(s) along
with the administration code(s). To obtain reimbursement for the vaccine serum, Medicaid
fee-for-service should be billed.
The PCP seeing Medicaid members must participate in the Vaccines for Children (VFC) program.
The PCP for Medicaid members must use the VFC supply and bill Amerigroup for the administrative
fee only. The VFC program covers children from birth to 18 years of age. Florida Medicaid requires
vaccines for Medicaid children from birth through 20 years of age. Members 19 through 20 years of
age should receive their vaccinations from their PCP.
The PCP for Florida Healthy Kids members should use his or her own vaccine supply and bill
Amerigroup for the vaccine and administrative fee. PCPs for FHK will be enrolled in the Florida
State Health Online Tracking System (SHOTS) statewide registry. Providers should bill Medicaid feefor-service directly for immunizations provided to Title XXI MediKids participants.
It is important that PCPs avoid sending Amerigroup members to local health departments for
immunizations. Amerigroup Florida Healthy Kids members are required to receive their immunizations
from their PCPs to ensure continuity of care, timeliness and accurate recordkeeping.
Role of the PCP
 Each Medicaid and Healthy Kids member will select or be assigned a PCP at the time of enrollment.
Medicaid membership is limited to 1,500 members per full-time PCP and may be increased by 750
members for each Advanced Registered Nurse Practitioner (ARNP) or physician extender affiliated
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with the physician, with a maximum of 3,000 active Amerigroup members. The PCP coordinates the
member’s health care needs through a comprehensive network of specialty, ancillary and hospital
providers.
For new members, the provider will contact each new member within 90 days of enrollment to
perform an initial health risk assessment. The provider will notify Amerigroup if he or she is unable
to contact the member within the 90-day enrollment period. Amerigroup will send a release form
to Medicaid members for the purpose of Amerigroup and state agency review. Once a release has
been signed, the PCP will request records from previous care providers. The PCP will use the
previous medical records and the health risk assessments to identify members who have not
received age-appropriate preventive health screenings (Child Health Check-Ups) for children from
birth through 20 years of age according to the standards established by the American Academy of
Pediatrics and endorsed by AHCA. Health screenings for adults will meet Amerigroup standards,
including those standards established by the Centers for Disease Control and Prevention and the
U.S. Preventive Services Task Force. When external regulating agencies impose more stringent
health screening standards, the PCP is required to comply with those standards.
The PCP is responsible 24 hours a day, 7 days a week for providing or arranging all covered services,
including prescribing, directing and obtaining appropriate authorizations of all care for members
who have been assigned to the PCP.
To the extent necessary, the PCP is responsible for coordinating coverage for members with an
alternate Amerigroup network physician. All financial arrangements must be made between the
PCP and covering physician. The PCP is also responsible for notifying Amerigroup in writing two
weeks prior to his or her absence of the duration of the absence and the physician who will be
providing the coverage. The covering physician must be an Amerigroup network physician.
All PCPs and physician extenders (ARNPs, PA) must be credentialed by Amerigroup or one of the
Amerigroup delegated credentialing entities. All personnel assisting in the provision of health care
services to members are to be appropriately trained, qualified and supervised in the care provided.
PCPs must notify their Provider Relations representative when a new provider joins the practice.
Anytime a new provider joins a practice, that individual must be credentialed with the plan and
cannot see members until the credentialing process is completed. Nonemergent services must not
be provided by a noncredentialed physician, and such services will not be covered by Amerigroup.
The PCP is responsible for the direct training and supervision of medical assistants. Duties of the
medical assistant will be strictly limited to those identified in the Florida Statutes, Section 458.3485.
All PCP facilities must have handicap accessibility, adequate space, supplies, good sanitation and
fire safety procedures in operation.
The PCP will only collect copayments from members when applicable and permitted under
Florida’s Medicaid law. The PCP must not charge any member for missed appointments.
PAs and ARNPs may not be assigned as the PCP for Amerigroup members.
Physician Extenders
Physician extenders (e.g., ARNPs, PAs) must be credentialed prior to seeing Amerigroup members.
They must clearly and appropriately identify themselves as an ARNP or PA to the member. Office staff
must appropriately refer to and identify physician extenders as ARNPs or PAs.
Supervising physicians must review, sign and date PA medical record entries within seven days in
accordance with F.A.C. 64B8-30.012 (3). Record entries of ARNPs do not require cosigning.
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Background Checks
Providers must complete a Level 2 criminal history background screening to determine whether their
subcontractors or any employees or volunteers of their subcontractors who meet the definition of
“direct service provider” have disqualifying offenses as provided for in s. 430.0402 F.S. as created and
s. 435.04, F.S. Any subcontractor, employee or volunteer of a subcontractor meeting the definition of a
“direct service provider” who has a disqualifying offense is prohibited from providing services to the
elderly as set forth in s. 430.0402, F.S.
Abuse, Neglect and Exploitation
Report elder abuse, neglect and exploitation to the statewide Elder Abuse Hotline at 1-800-96ABUSE
(1-800-962-2873).
Abuse means any willful act or threatened act by a caregiver that causes or is likely to cause significant
impairment to an enrollee’s physical, mental, or emotional health. Abuse includes acts and omissions.
Exploitation of a vulnerable adult means a person who:
1. Stands in a position of trust and confidence with a vulnerable adult and knowingly, by deception or
intimidation, obtains or uses, or endeavors to obtain or use a vulnerable adult’s funds, assets or
property for the benefit of someone other than the vulnerable adult
2. Knows or should know that the vulnerable adult lacks the capacity to consent, and obtains or uses,
or endeavors to obtain or use, the vulnerable adult’s funds, assets, or property with the intent to
temporarily or permanently deprive the vulnerable adult of the use, benefit or possession of the
funds, assets or property for the benefit of someone other than the vulnerable adult
Neglect of an adult means the failure or omission on the part of the caregiver to provide the care,
supervision and services necessary to maintain the physical and behavioral health of the vulnerable
adult, including but not limited to food, clothing, medicine, shelter, supervision and medical services
that a prudent person would consider essential for the well-being of the vulnerable adult. The term
neglect also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult
from abuse, neglect or exploitation by others. Neglect is repeated conduct or a single incident of
carelessness that produces or could reasonably be expected to result in serious physical or
psychological injury or a substantial risk of death.
PCP Access and Availability
All providers are expected to meet the federal and state accessibility standards and those defined in
the Americans with Disabilities Act of 1990. Health care services provided through Amerigroup must be
accessible to all members.
Amerigroup is dedicated to arranging access to care for our members. The ability of Amerigroup to
provide quality access depends upon the accessibility of network providers. Providers are required to
adhere to the following access standards:
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Service
Emergent or emergency visits
Urgent, nonemergency visits
Routine visits
Waiting time
Walk-in patients (nonurgent)
Walk-in patients (urgent)
Access Requirement
Immediately upon presentation
Within 24 hours
Within 30 days
Should not exceed 45 minutes for scheduled appointment of routine
nature
Seen if possible or scheduled, consistent with standards
Within 48 hours
Providers may not use discriminatory practices such as preference to other insured or private-pay
patients, separate waiting rooms, or appointment days.
Amerigroup will routinely monitor providers’ adherence to the access care standards.
To ensure continuous 24-hour coverage, PCPs must maintain one of the following arrangements for
their members to contact the PCP after normal business hours:
 Have the office telephone answered after hours by an answering service, which can contact the
PCP or another designated network medical practitioner; all calls answered by an answering service
must be returned within 30 minutes
 Have the office telephone answered after normal business hours by a recording in the language of
each of the major population groups served by the PCP, directing the member to call another
number to reach the PCP or another provider designated by the PCP; someone must be available to
answer the designated provider’s telephone; another recording is not acceptable
 Have the office telephone transferred after office hours to another location where someone will
answer the telephone and be able to contact the PCP or a designated Amerigroup network medical
practitioner, who can return the call within 30 minutes
The following telephone answering procedures are not acceptable:
 Only answering office telephone during office hours
 Only answering office telephone after hours by a recording that tells members to leave a message
 Answering office telephone after hours by a recording that directs members to go to an emergency
room for any services needed
 Returning after-hours calls outside of 30 minutes
Member Missed Appointments
Amerigroup members may sometimes cancel or not appear for necessary appointments and fail to
reschedule the appointment. This can be detrimental to their health. Amerigroup requires providers to
attempt to contact members who have not shown up for or canceled an appointment without
rescheduling the appointment. The contact must be by telephone and should be designed to educate
the member about the importance of keeping appointments and to encourage the member to
reschedule the appointment.
Amerigroup members who frequently cancel or fail to show up for an appointment without
rescheduling the appointment may need additional education in appropriate methods of accessing
care. Members who miss three consecutive appointments within a six-month period may be
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considered for disenrollment from a provider’s panel. Such requests must be submitted at least 60
calendar days prior to the requested effective date. In these cases, please call Provider Services at our
National Customer Care department at 1-800-454-3730 to address the situation. Amerigroup staff will
contact the member and provide more extensive education and/or case management as appropriate.
Our goal is for members to recognize the importance of maintaining preventive health visits and to
adhere to a plan of care recommended by their PCP. Please note that the provider agrees not to charge
a member for missed appointments.
Noncompliant Amerigroup Members
Amerigroup recognizes that providers may need help in managing noncompliant members. If you have
an issue with a member regarding behavior, treatment cooperation and/or completion of treatment,
and/or making or appearing for appointments, please contact our National Customer Care department
at 1-800-454-3730.
PCP Transfers
In order to maintain continuity of care, Amerigroup encourages members to remain with their PCP.
However, members may request to change their PCP for any reason by contacting our National
Customer Care department at 1-800-600-4441. The member’s name will be provided to the PCP on the
membership roster.
Members can call to request a PCP change any day of the month. PCP change requests will be
processed generally on the same day or by the next business day. Members will receive a new ID card
within 10 days.
Covering Physicians
During a provider’s absence or unavailability, the provider needs to arrange for coverage for his or her
members. The provider will either (i) make arrangements with one or more network providers to
provide care for his or her members or (ii) make arrangements with another similarly licensed and
qualified provider who has appropriate medical staff privileges at the same network hospital or
medical group, as applicable, to provide care to the members in question. In addition, the covering
provider will agree to the terms and conditions of the network provider agreement, including without
limitation, any applicable limitations on compensation, billing and participation. Providers will be solely
responsible for a non-network provider’s adherence to such provisions. Providers will be solely
responsible for any fees or monies due and owed to any non-network provider providing substitute
coverage to a member on the provider’s behalf.
Specialist as a PCP
Under certain circumstances, when a member requires the regular care of the specialist, a specialist
may be approved by Amerigroup to serve as a member’s PCP. The criteria for a specialist to serve as a
member’s PCP include the member having a chronic, life-threatening illness or condition of such
complexity whereby:
 The need for multiple hospitalizations exists
 The majority of care needs to be given by a specialist
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The administrative requirements arranging for care exceed the capacity of the nonspecialist 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 its determination in writing within 30 days of
receiving the request. Should Amerigroup deny the request, Amerigroup will provide written
notification to the member and provider outlining the reason(s) for the denial of the request within
one day of the decision. Specialists serving as PCPs will continue to be paid 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 located in the Appendix A — Forms section of this manual.
Specialty Referrals
In order to reduce the administrative burden on the provider’s office staff, Amerigroup has established
procedures that are designed to permit a member with a condition that requires ongoing care from a
specialist physician or other health care provider to request an extended authorization.
The provider can request an extended authorization by contacting the member’s PCP. The provider
must supply the necessary clinical information that will be reviewed by the PCP to complete the
authorization review.
On a case-by-case basis, an extended authorization will be approved. In the event of termination of a
contract with the treating provider, the continuity-of-care provisions in the provider’s contract with
Amerigroup will apply. The provider may renew the authorization by submitting a new request to the
PCP. Additionally, Amerigroup requires the specialist physician or other health care provider to provide
regular updates to the member’s PCP (unless acting also as the designated PCP for the member).
Should the need arise for a secondary referral, the specialist physician or other health care provider
must contact Amerigroup for a coverage determination.
If the specialist or other health care provider needed to provide ongoing care for a specific condition is
not available in the Amerigroup network, the referring physician shall request authorization from
Amerigroup for services outside the network. Access will be approved to a qualified non-network
health care provider within a reasonable distance and travel time at no additional cost if medical
necessity is met.
If a provider’s application for an extended authorization is denied, the member (or the provider on
behalf of the member) may appeal the decision through the Amerigroup medical appeal process.
Second Opinions
A member, parent, and/or legally appointed representative or the member’s PCP may request a
second opinion in any situation where there is a question concerning a diagnosis or the options for
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surgery or other treatment of a health condition. The second opinion shall be provided at no cost to
the member.
The second opinion must be obtained from a network provider (see provider referral directory) or with
precertification 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 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 our own discretion. This may occur under the
following circumstances:
 Whenever there is a concern about care expressed by the member or the provider
 Whenever potential risks or outcomes of recommended or requested care are discovered by the
plan during its regular course of business
 Before initiating a denial of coverage of service
 When denied coverage is appealed
 When an experimental or investigational service is requested
When Amerigroup requests a second opinion, Amerigroup will make the necessary arrangements for
the appointment, payment and reporting. Amerigroup will inform the member and the PCP of the
results of the second opinion and the consulting provider’s conclusion and recommendation(s)
regarding further action.
Specialty Care Providers
To participate in the Medicaid managed care model, the provider must have applied for enrollment in
the Florida Medicaid and Florida Healthy Kids program and be a licensed provider by the state before
signing a contract with Amerigroup.
Amerigroup contracts with a network of provider specialty types to meet the medical specialty needs
of members and provide all medically necessary covered services. The specialty care provider is a
network physician who has the responsibility for providing specialized care for members, usually upon
appropriate referral from a PCP within the network (see Role and Responsibility of the Specialty Care
Provider section). In addition to sharing many of the same responsibilities to members as the PCP
(see Responsibilities of the PCP), the specialty care provider provides services that include:
 Allergy and immunology services
 Burn services
 Community behavioral health (e.g., mental health and substance abuse) services
 Cardiology services
 Clinical nurse specialists, psychologists and clinical social workers (i.e., behavioral health)
 Critical care medical services
 Dermatology services
 Endocrinology services
 Gastroenterology services
 General surgery
 Hematology/oncology services
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Neonatal services
Nephrology services
Neurology services
Neurosurgery services
Ophthalmology services
Orthopedic surgery services
Otolaryngology services
Perinatal services
Pediatric services
Psychiatry (adult) assessment services
Psychiatry (child and adolescent) assessment services
Trauma services
Urology services
Role and Responsibility of the Specialty Care Provider
Members may self-refer to a participating specialist provider, including mental health and substance
abuse providers. Obligations of the specialist include, but are not limited to, the following:
 Complying with all applicable statutory and regulatory requirements of the Medicaid program
 Accepting all Amerigroup members who self-refer or are directed to the specialist provider for care
 Submitting required claims information
 Arranging for coverage with network providers while off duty or on vacation
 Verifying member eligibility and precertification of services (if required) at each visit
 Providing consultation summaries or appropriate periodic progress notes to the member’s PCP on a
timely basis, following a referral or routinely scheduled consultative visit
 Notifying the member’s PCP when scheduling a hospital admission or scheduling any procedure
 Coordinating care, as appropriate, with other providers involved in providing care for members,
especially in cases where there are medical and behavioral health comorbidities or co-occurring
mental health and substance abuse disorders
The specialist will:
 Manage the medical and health care needs of members, including monitoring and following up on
care provided by other providers, including those engaged on a Fee-For-Service (FFS) basis; provide
coordination necessary for referrals to other specialists and FFS providers (both in and out of
network); and maintain a medical record of all services rendered by the specialist and other
providers
 Provide 24 hours a day, 7 day a week coverage and maintain regular hours of operation that are
clearly defined and communicated to members
 Provide services ethically and legally in a culturally competent manner and meet the unique needs
of members with special health care requirements
 Participate in the systems established by Amerigroup that facilitate the sharing of records, subject
to applicable confidentiality and HIPAA requirements
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Participate and cooperate with Amerigroup in any reasonable internal or external quality assurance,
utilization review, continuing education, or other similar programs established by Amerigroup
Make reasonable efforts to communicate, coordinate and collaborate with other specialty care
providers, including behavioral health providers, involved in delivering care and services to members
Participate in and cooperate with the Amerigroup complaint and grievance processes and procedures;
Amerigroup will notify the specialist of any member grievance brought against the specialist
Not balance bill members
Continue care in progress during and after termination of his or her contract for up to 60 days until
a continuity of care plan is in place to transition the member to another provider or through
postpartum care for pregnant members in accordance with applicable state laws and regulations
Comply with all applicable federal and state laws regarding the confidentiality of patient records
Develop and have an exposure control plan regarding blood-borne pathogens in compliance with
OSHA standards
Make best efforts to fulfill the obligations under the ADA applicable to his or her practice location
Support, cooperate and comply with the Amerigroup Quality Management Program initiatives and
any related policies and procedures designed to provide quality care in a cost-effective and
reasonable manner
Inform Amerigroup if a member objects for religious reasons to the provision of any counseling,
treatment or referral services
Treat all members with respect and dignity; provide members with appropriate privacy and treat
member disclosures and records confidentially, giving the members the opportunity to approve or
refuse their release as allowed under applicable laws and regulations
Provide to members complete information concerning their diagnosis, evaluation, treatment and
prognosis and give members the opportunity to participate in decisions involving their health care,
except when contraindicated for medical reasons
Advise members about their health status, medical care or treatment options, regardless of
whether benefits for such care are provided under the program and advise members on
treatments that may be self-administered
When clinically indicated, contact members as quickly as possible for follow-up regarding
significant problems and/or abnormal laboratory or radiological findings
Have a policy or procedure to ensure proper identification, handling, transport, treatment and
disposal of hazardous and contaminated materials and wastes to minimize sources and
transmission of infection
Agree to maintain communication with the appropriate agencies such as local police, social services
agencies and poison control centers to provide quality patient care
Agree that any notation in a patient’s clinical record indicating diagnostic or therapeutic
intervention that is part of a clinical research study is clearly distinguished from entries pertaining
to nonresearch-related care
Specialty Care Providers Access and Availability
Amerigroup will maintain a specialty network to ensure access and availability to specialists for all
members. A provider is considered a specialist if he or she has a provider agreement with Amerigroup
to provide specialty services to members.
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Specialist must adhere to the following access guidelines:
Service
Access Requirement
Urgent, nonemergency visits
Within 24 hours
Routine visits
Within 30 days
Maternity care – 1st Trimester
Within 14 days
Maternity care – 2nd Trimester
Within 7 days
Maternity care – 3rd Trimester
Within 3 business days
High-risk pregnancies
Within 3 business days
Open-Access Specialist Providers
Members may self-refer to the network providers listed below without a PCP referral. Providers should
establish processes for the identification of the member’s PCP and forward information concerning the
member’s evaluation and treatment to the PCP after obtaining consent from the member as
appropriate under legal requirements.
 Chiropractors
 Podiatrists
 Dermatologists
 OB/GYN
Cultural Competency
Cultural competency refers to the ability of individuals and systems to provide services effectively to
people of all cultures, races, ethnic backgrounds and religions in a manner that recognizes values,
affirms and respects the worth of individuals, and protects and preserves the dignity of each.
Amerigroup promotes cultural competency. We collect information regarding the cultural differences
of our members and provide training opportunities to staff and network providers, helping them learn
ways to interact effectively with members. Staff and provider cultural competency is monitored as part
of the Quality Improvement process.
Amerigroup has a comprehensive written Cultural Competency Plan (CCP) describing the health plan’s
program to ensure that services are provided in a culturally competent manner to all enrollees. The
CCP is updated yearly and can be accessed via the provider website, or you can call and request a copy
at no cost to you by calling 1-800-454-3730.
Marketing
When it comes to marketing, you need to be aware of and comply with the following:
 Providers are permitted to make available and/or distribute Amerigroup marketing materials as
long as the provider and/or the facility distributes or makes available marketing materials for all
Managed Care Plans with which the provider participates. Providers are also permitted to display
posters or other materials in common areas such as the provider’s waiting room. Additionally, longterm care facilities are permitted to provide materials in admission packets announcing all
Managed Care Plan contractual relationships.
 We will provide education, outreach and monitoring to ensure you are aware of and comply with
the following:
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1. To the extent a provider can assist a recipient in an objective assessment of his or her needs
and potential options to meet those needs, the provider may do so. Providers may engage
in discussions with recipients should a recipient seek advice. However, providers must
remain neutral when assisting with enrollment decisions.
2. Providers may not:
a. Offer marketing/appointment forms
b. Make phone calls or direct, urge or attempt to persuade recipients to enroll in a
Managed Care Plan based on financial or any other interests of the provider
c. Mail marketing materials on behalf of a Managed Care Plan
d. Offer anything of value to induce recipients/enrollees to select them as their
provider
e. Offer inducements to persuade recipients to enroll in the Managed Care Plan
f. Conduct health screening as a marketing activity
g. Accept compensation directly or indirectly from the Managed Care Plan for
marketing activities
h. Distribute marketing materials within an exam room setting
i. Furnish to the Managed Care Plan lists of their Medicaid patients or the membership
of any Managed Care Plan
3. Providers may:
a. Provide the names of the Managed Care Plans with which they participate
b. Make available and/or distribute Managed Care Plan marketing materials
c. Refer their patients to other sources of information, such as the Managed Care Plan,
the enrollment broker or the local Medicaid Area Office
d. Share information with patients from the Agency’s website or the CMS website
Provider Affiliation Information
1. Providers may announce new or continuing affiliations with the Managed Care Plan through
general advertising (e.g., radio, television, websites).
2. Providers may make new affiliation announcements within the first 30 calendar days of the
new provider agreement.
3. Providers may make one announcement to patients of a new affiliation that names only the
Managed Care Plan when such announcement is conveyed through direct mail, email or
phone.
4. Additional direct mail and/or email communications from providers to their patients
regarding affiliations must include a list of all Managed Care Plans with which the provider
contracts.
5. Any affiliation communication materials that include Managed Care Plan-specific
information (e.g., benefits, formularies) must be prior approved by the Agency.
Providers may distribute printed information provided by the Managed Care Plan to their patients
comparing the benefits of all of the different Managed Care Plans with which the providers
contract.
Member Records
Providers are required to maintain medical records for each patient in accordance with the medical
record requirements below and with 42 CFR 431 and 42 CFR 456. A permanent medical record will be
maintained at the primary care site for every member and be available to the PCP and other
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physicians. Medical records shall include the quality, quantity, appropriateness and timeliness of
services performed.
Providers are required to have a designated person in charge of medical records. This person’s
responsibilities include, but are not limited to:
1. The confidentiality, security and physical safety of records
2. The timely retrieval of individual records upon request
3. The unique identification of each patient’s record
4. The supervision of the collection, processing, maintenance, storage and appropriate access to the
usage of records
5. The maintenance of a predetermined, organized and secured record format
Medical Record Standards
Except when otherwise required by law, the content and format of clinical records, including the
sequence of information, are uniform. Records are organized in a consistent manner that facilitates
continuity of care.
All patient medical records are to reflect all aspects of patient care, including ancillary services.
Providers shall follow the medical record standards set forth below for each member’s medical
records, as appropriate:
 Include the enrollee's identifying information, including name, enrollee identification number, date
of birth, gender, and legal guardianship or responsible party, if applicable
 Maintain each record legibly and in detail
 Include a summary of significant surgical procedures, past and current diagnoses or problems,
allergies, untoward reactions to drugs and current medications and any other health conditions
 Record the presence or absence of allergies and untoward reactions to drugs, current medications
and/or materials in a prominent and consistent location in all clinical records; this information
should be verified at each patient encounter and updated whenever new allergies or sensitivities
are identified
 Ensure all entries are dated and signed by the appropriate party
 Indicate in all entries the chief complaint or purpose of the visit, the objective, diagnoses, and
medical findings or impression of the provider
 Indicate in all entries the studies ordered (e.g., laboratory, X-ray, electrocardiogram) and referral
reports
 Indicate in all entries the therapies administered and prescribed
 Record all medications prescribed and documentation or medication reconciliation, including any
changes in prescription and nonprescription medication with name and dosage when available
 Include in all entries the name and profession of the provider rendering services (e.g., M.D., D.O.),
including the provider’s signature or initials
 Include in all entries the disposition, recommendations, instructions to member, evidence of
follow-up and outcome of services
 Include copies of any consent or attestation form used or the court order for prescribed
psychotherapeutic medication for children under age of thirteen (13)
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Ensure all records contain an immunization history and documentation of body mass index
Ensure all records contain information relating to the member’s use of tobacco products and
alcohol and/or substance abuse
Ensure all records contain summaries of all emergency services and care and hospital discharges
with appropriate and medically indicated follow-up
Document referral services in all members’ medical records
Include all services provided such has family planning services, preventive services and services for
the treatment of sexually transmitted diseases
Ensure all records reflect the primary language spoken by the member and any translation needs of
the member
Ensure all records identify members needing communication assistance in the delivery of health
care services
Ensure all records contain documentation of the member being provided with written information
concerning his or her rights regarding advance directives (i.e., written instructions for living will or
power of attorney) and whether or not he or she has executed an advance directive (Note: neither
the health plan nor any of its providers shall require, as a condition of treatment, the member to
execute or waive an advance directive. The health plan must maintain written policies and
procedures for advance directives)
Maintain copies of any advance directives executed by the member
Enter in the patient’s clinical record and appropriately sign or initial significant medical advice given
to a patient by telephone or online, including medical advice provided after hours
Clearly contrast any notation in a patient’s clinical record indicating diagnostic or therapeutic
intervention as part of clinical research with entries regarding the provision of nonresearch-related
care
Review and incorporate into the record in a timely manner all reports, histories, physicals, progress
notes and other patient information such as laboratory reports, X-ray readings, operative reports
and consultations
Document a summary of past and current diagnoses or problems, including past procedures if a
patient has had multiple visits/admissions or the clinical record is complex and lengthy
Include a notation concerning cigarettes if present for patients ages 12 and older; abbreviations
and symbols may be appropriate
Screen patients for substance abuse and document in the medical record as part of a prevention
evaluation during the following times:
1. Initial contact with a new member
2. Routine physical examinations
3. Initial prenatal contact
4. When the member evidences serious overutilization of medical surgical, trauma or emergency
services
5. When documentation of emergency room visits suggests the need
Provide health education to the member
The following requirements must also be met regarding the patient’s medical records:
1. Consultations, referrals and specialist reports — Notes from any referrals and consultations must
be in the record. Consultation, lab and X-ray reports filed in the chart must have the ordering
physician’s initials or other documentation signifying review. Consultation and any abnormal lab
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and imaging study results must have an explicit notation in the record of follow-up plans, including
timely notification with patient or responsible party (adult).
2. Emergencies — All emergency care provided directly by the contracted provider or through an
emergency room and the hospital discharge summaries for all hospital admissions while the patient
is part of the PCP’s panel must be noted.
3. Hospital discharge summaries — Discharge summaries must be included as part of the medical
record for all hospital admissions that occur while the patient is enrolled and for prior admissions,
as appropriate. Prior admissions pertaining to admissions that may have occurred prior to the
patient being enrolled may be pertinent to the patient’s current medical condition.
4. Security — Providers must maintain a written policy and are required to ensure that medical
records are safeguarded against loss, tampering, alteration, destruction, or unauthorized use or
inadvertent use.
5. Storage — Providers must maintain a system for the proper collection, processing, maintenance,
storage, retrieval and distribution of patient’s records. Also, the records must be easily accessible
to personnel in the provider’s office and readily available to authorized personnel any time the
organization is open to patients.
6. Release of information — Written procedures are required for releasing information and obtaining
consent for treatment.
7. Documentation — Documentation is required setting forth the results of medical, preventive and
behavioral health screenings as well as all treatment provided and the outcome of such treatment,
including significant medical advice given to a patient by telephone.
8. Multidisciplinary teams — Documentation is required of the team members involved in the
multidisciplinary team of a patient needing specialty care.
9. Integration of clinical care — Documentation of the integration of clinical care in both the physical
and behavioral health records is required. Such documentation must include:
- Screening for behavioral health conditions, including those which may be affecting physical
health care and vice versa, and referral to behavioral health providers when problems are
indicated
- Screening and referral by behavioral health providers to PCPs when appropriate
- Receipt of behavioral health referrals from physical medicine providers and the
disposition/outcome of those referrals
- At least quarterly, or more often if clinically indicated, a summary of the status/progress from
the behavioral health provider to the PCP
- A written release of information that will permit specific information-sharing between
providers
- Documentation that behavioral health professionals are included in primary and specialty care
service teams when a patient with disabilities or chronic or complex physical or developmental
conditions has a co-occurring behavioral disorder
10. Domestic violence — Documentation of screening and referral to applicable domestic violence
prevention community agencies is required.
11. Consent for psychotherapeutic medications — Pursuant to Statute F.S. 409.912(51), providers must
document in the medical record informed consent from the parent or legal guardian of members
younger than 13 who are prescribed psychotherapeutic medications and must provide the
pharmacy with a signed attestation of this documentation. Pharmacies are required to obtain and
keep these consents on file prior to filing a psychotherapeutic medication.
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12. Behavioral health services provided through telemedicine – Documentation of behavioral health
services provided through telemedicine is required. Such documentation must include:
 A brief explanation of the use of telemedicine in each progress note
 Documentation of telemedicine equipment used for the particular covered services provided
 A signed statement from the enrollee or the enrollee’s representative indicating the choice to
receive services through telemedicine. This statement may be for a set period of treatment or
for a one-time visit, as applicable to the service(s) provided; and
 For telepsychiatry the results of the assessment, findings and practitioner(s) plan for next steps.
Amerigroup will periodically review medical records to ensure compliance with these standards.
Amerigroup will institute actions, including corrective actions for improvement, when standards are
not met.
Patient Visit Data
Documentation of individual encounters must provide adequate evidence of the following, at a
minimum:
1. Date of service; name, signature and profession (e.g., M.D., O.D., RN) of the person(s) providing the
service; type of service provided; department of facility (if applicable); chief complaint; changes in
medications with name and dosage; disposition; recommendations or instructions provided; and
documentation of missed or cancelled appointments
2. A history and physical exam that includes appropriate subjective and objective information
obtained for the presenting complaints
3. For patients receiving behavioral health treatment, documentation that includes at-risk factors
such as danger to self and/or others, ability to care for self, affect, perceptual disorders, cognitive
functioning, and significant social health
4. An admission or initial assessment that includes current support systems or lack of support systems
5. For patients receiving behavioral health treatment, a documented assessment that is done with
each visit relating to client status/symptoms and that may indicate initial symptoms of the
behavioral health condition as decreased, increased or unchanged during the treatment period,
along with the type and units of service provided
6. A plan of treatment that includes activities/therapies to be carried out and goals to be met
7. For patients receiving behavioral health treatment, a treatment plan that includes the member
and/or parent or guardian’s preferences for treatment, identifies reasonable and appropriate
objectives, provides the necessary services to meet the objectives, and includes a retrospective
review to confirm that care provided and its outcomes were consistent with the approved
treatment and member’s needs
8. Diagnostic tests
9. Documented therapies and other prescribed regimens for patients who receive behavioral health
treatment and show evidence of family involvement as applicable and include evidence that the
family was included in therapy sessions when appropriate
10. For follow-up care encounter forms or notes with a notation indicating follow-up care, a call or a
visit that must note in weeks, months or PRN (as needed) the specific time to return
with unresolved problems from any previous visits being addressed in subsequent visits
11. Referrals and results, including all other aspects of patient care, such as ancillary services
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Amerigroup will systematically review medical records to ensure compliance with these standards. We
will share the results of our audits and institute actions for improvement when standards are not met.
We maintain an appropriate record-keeping system for services to members. This system will collect all
pertinent information relating to the medical management of each member and make that
information readily available to appropriate health professionals and appropriate state agencies. All
records will be retained in accordance with the record retention requirements of 45 CFR 74.164, which
states that records must be retained for seven years from the date of service.
Misrouted Protected Health Information
Providers and facilities are required to review all member information received from Amerigroup to
ensure no misrouted Protected Health Information (PHI) is included. Misrouted PHI includes
information about members that a provider or facility is not treating. PHI can be misrouted to
providers and facilities by mail, fax, email or electronic remittance advice. Providers and facilities are
required to immediately destroy misrouted PHI or safeguard the PHI for as long as it is retained. In no
event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or
facilities cannot destroy or safeguard misrouted PHI, please call our Provider Services team at
1-800-454-3730 for help.
Clinical Practice Guidelines
Using nationally recognized standards of care, Amerigroup works with providers to develop clinical
policies and guidelines for the care of our membership. The Medical Advisory Committee (MAC)
oversees and directs Amerigroup in formulating, adopting and monitoring guidelines.
Amerigroup select at least four evidence-based clinical practice guidelines that are relevant to the
member population. We then measure performance against at least two important aspects of each of
the four clinical practice guidelines annually. The guidelines must be reviewed and revised at least
every two years or whenever the guidelines change.
Amerigroup uses the following clinical practice guidelines:
 Asthma over age 5 per the
 HIV/AIDS
National Heart, Lung and Blood Institute
 Hypertension
 Asthma under age 5
 Immunization schedules
 Attention deficit hyperactivity disorder
 Major depressive disorder
 Bipolar disorder
 Obesity
 Chronic kidney disease
 Obstetrical care
 Chronic obstructive pulmonary disease
 Preventive health – adult comparison grid
 Congestive heart failure
 Preventive pediatric care
 Coronary artery disease
 Schizophrenia
 Diabetes mellitus
 Synagis criteria
 Family planning preventive health
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
Gestational diabetes mellitus and
pregnancy-induced hypertension

Florida Synagis algorithm
The clinical practice guidelines are developed based on the recommendations of industry specialty
associations and organizations, including the following:
 American Academy of Child and Adolescent Psychiatry
 American Academy of Family Physicians
 American Academy of Pediatrics
 American Cancer Society
 American College of Obstetricians and Gynecologists (ACOG)
 American College of Physicians
 American Diabetes Association
 American Lung Association
 American Medical Association
 Centers for Disease Control and Prevention
 Department of Health and Human Services Commission
 National Institutes of Health
 U.S. Preventive Services Task Force
Visit our provider website at providers.amerigroup.com/FL to review the clinical practice guidelines.
Advance Directives
Amerigroup respects the right of the member to control decisions relating to his or her own medical
care, including the decision to have provided, withheld or withdrawn the medical or surgical means or
procedures calculated to prolong his or her life. This right is subject to certain interests of society, such
as the protection of human life and the preservation of ethical standards in the medical profession.
Amerigroup adheres to The Patient Self-Determination Act and maintains written policies and
procedures regarding advance directives. Advance directives are documents signed by a competent
person giving direction to health care providers about treatment choices in certain circumstances.
There are two types of advance directives. A durable power of attorney for health care (i.e., durable
power) allows the member to name a patient advocate to act on behalf of the member. A living will
allows the member to state his or her wishes in writing but does not name a patient advocate.
Member Services and Outreach associates encourage members to request an advance directive form
and education from their PCP at their first appointment.
Members over age 18 and emancipated minors are able to make an advance directive. His or her
response is to be documented in the medical record. Amerigroup will not discriminate or retaliate
based on whether a member has or has not executed an advance directive.
While each member has the right without condition to formulate an advance directive within certain
limited circumstances, a facility or an individual physician may conscientiously object to an advance
directive.
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Member Services and Outreach associates will assist members regarding questions about advance
directives; however, no associate of Amerigroup may serve as witness to an advance directive or as a
member’s designated agent or representative.
Amerigroup notes the presence of advance directives in the medical records when conducting medical
chart audits. A living will and durable power of attorney forms are located in Appendix A — Forms.
Telemedicine
If you have been approved by us to provide services through telemedicine, you must implement
telemedicine fraud and abuse protocols that address:
 Authentication and authorization of users
 Authentication of the origin of the information
 The prevention of unauthorized access to the system or information
 System security, including the integrity of information that is collected, program integrity and
system integrity
 Maintenance of documentation about system and information usage
If approved to provide dental services through telemedicine, only the following medically necessary
dental services may be provided:
1. Oral prophylaxis
2. Topical fluoride application
3. Oral hygiene instructions.
The services listed above performed via telemedicine must be provided by a Florida-licensed dental
hygienist at a spoke site with a supervising Florida-licensed dentist located at a hub site. For such
dental services, mobile dental units as defined in the Dental Services Coverage and Limitations
Handbook may be used as a spoke site.
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MEDICAL MANAGEMENT
Medical Review Criteria
On December 24, 2012, WellPoint, Inc. (WellPoint) acquired Amerigroup Corporation and its
subsidiaries. WellPoint has its own nationally recognized medical policy process for all of its subsidiary
entities.
Effective March 1, 2014, WellPoint medical policies, which are publicly accessible from its UniCare
subsidiary website, became the primary benefit plan policies for determining whether services are
considered to be a) investigational/experimental, b) medically necessary, and c) cosmetic or
reconstructive for Amerigroup subsidiaries.
A list of the specific UniCare Clinical UM Guidelines used is posted and maintained on the Amerigroup
provider self-service websites and can be obtained in hard copy by written request. The policies
described above will support precertification requirements, clinical-appropriateness claims edits and
retrospective review.
Federal and state law, as well as contract language, including definitions and specific contract
provisions/exclusions, take precedence over medical policy and must be considered first when
determining eligibility for coverage. As such, in all cases, state Medicaid contracts or Centers for
Medicare & Medicaid Services (CMS) requirements will supersede UniCare medical policy criteria.
Medical technology is constantly evolving, and we reserve the right to review and periodically update
medical policy and utilization management criteria.
McKesson InterQual is used for nonbehavioral health concurrent review determinations only
through March 1, 2014. Effective March 1, 2014, Amerigroup Corporation and its health plan
subsidiaries no longer use McKesson InterQual Care Planning and Behavioral Health criteria to
determine medical necessity for non-behavioral health and behavioral health inpatient and outpatient
precertification reviews. Except in cases where superseded by state Medicaid or Centers for Medicare
& Medicaid Services (CMS) requirements, all non-behavioral health, and behavioral health inpatient
and outpatient precertification requests and Behavioral Health concurrent reviews will be determined
using WellPoint’s UniCare medical policies and clinical utilization management guidelines.
McKesson InterQual will continue to be used for non-behavioral health concurrent review determinations
after March 1, 2014.
We work with network providers to develop clinical guidelines of care for our membership. The
Medical Advisory Committee assists us in formalizing and monitoring guidelines.
If we utilize noncommercial criteria, the following standards apply to the development of the criteria:
 Criteria are developed with involvement from appropriate providers with current knowledge
relevant to the content of treatment guidelines under development.
 Criteria are based on review of market practice and national standards/best practices.
 Criteria are evaluated at least annually by appropriate, actively practicing physicians and other
providers with current knowledge relevant to the criteria of treatment guidelines under review and
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updated, as necessary. The criteria must reflect the names and qualifications of those involved in
the development, the process used in the development, and when and how often the criteria will
be evaluated and updated.
UM Decision Making
Amerigroup, as a corporation and as individuals involved in Utilization Management (UM) decisions, is
governed by the following statements:
 UM decision-making is based only on appropriateness of care and service and existence of coverage.
 Amerigroup does not specifically reward practitioners or other individuals for issuing denial of
coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff
are not based on the likelihood or perceived likelihood that they support, or tend to support
denials of benefits.
 Financial incentives for UM decision-makers do not encourage decisions that result in
underutilization, or create barriers to care and service.
Clinical Criteria
Amerigroup utilizes nationally recognized standards of care for clinical decision support for medical
management coverage decisions. The criteria provide a system for screening proposed medical care based
on member-specific best medical care practices and rule-based systems to match appropriate services to
member needs based upon clinical appropriateness. Criteria include:
 Acute care
 Home care
 Rehabilitation
 Surgery and procedures
 Subacute care
 Imaging studies and X-rays
Amerigroup utilization reviewers use these criteria as part of the precertification of scheduled
admission, concurrent review and discharge planning process to determine clinical appropriateness
and medical necessity for coverage of continued hospitalization.
Precertification/Notification Process
Amerigroup may require members to seek a referral from their PCP prior to accessing nonemergency
specialty physical health services. Precertification is defined as the prospective process whereby
licensed clinical associates apply designated criteria sets against the intensity of services to be
rendered and a member’s severity of illness, medical history and previous treatment to determine the
medical necessity and appropriateness of a given coverage request. Prospective means the coverage
request occurred prior to the service being provided. Notification is defined as telephonic, facsimile or
electronic communication received from a provider informing Amerigroup of the intent to render
covered medical services to a member. There is no review against medical necessity criteria; however,
member eligibility and provider status (network and non-network) are verified. Notification should be
provided prior to rendering services as referenced in the Quick Reference Card. For services that are
emergent or urgent, notification should be given within 24 hours or the next business day.
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HOSPITAL AND ELECTIVE ADMISSION MANAGEMENT
Amerigroup requires precertification of all inpatient elective admissions. The referring primary care
provider (PCP) or specialist physician is responsible for precertification.
The referring physician identifies the need to schedule a hospital admission and must submit the
request to the Amerigroup Medical Management department.
Requests for precertification with all supporting documentation should be submitted immediately
upon identifying the inpatient request or at least 72 hours prior to the scheduled admission. This will
allow Amerigroup to verify benefits and process the precertification request. For services that require
precertification, Amerigroup makes case-by-case determinations that consider the individual’s health
care needs and medical history, in conjunction with medical necessity criteria.
The hospital can confirm that an authorization is on file by calling the Amerigroup automated Provider
Inquiry Line at 1-800-454-3730. If coverage of an admission has not been approved, the facility should
call Amerigroup at 1-800-454-3730. Amerigroup will contact the referring physician directly to resolve
the issue.
Amerigroup is available 24 hours a day, 7 days a week to accept precertification requests. When a
request is received from the physician via telephone or fax for medical services, the care specialist will
verify eligibility and benefits. This information will be forwarded to the precertification nurse.
The precertification nurse will review the coverage request and the supporting medical documentation
to determine the medical appropriateness of diagnostic and therapeutic procedures. When
appropriate, the precertification nurse will assist the physician in identifying alternatives for health
care delivery as supported by the medical director.
When the clinical information received is in accordance with the definition of medical necessity and in
conjunction with UniCare Clinical UM Guidelines criteria, an Amerigroup reference number will be
issued to the referring physician. All utilization guidelines must be supported by an individualized
determination of medical necessity based on the member’s needs and medical history.
If medical necessity criteria for the admission are not met on the initial review, the medical director
will contact the requesting physician to discuss the case.
If the precertification documentation is incomplete or inadequate, the precert nurse will not approve
coverage of the request but will notify the referring provider to submit the additional necessary
documentation. Two requests for additional information will be made over a 48-hour period. If
information is not received within the specified time period, the request will be denied.
If the medical director denies coverage of the request, the appropriate denial letter (including the
member’s appeal rights) will be mailed to the requesting provider, the member’s PCP and the member.
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Emergent Admission Notification Requirements
Amerigroup prefers immediate notification by network hospitals of emergent admissions. Network
hospitals must notify Amerigroup of emergent admissions within one business day. Amerigroup
Medical Management staff will verify eligibility and determine benefit coverage.
Amerigroup is available 24 hours a day, 7 days a week to accept emergent admission notification at our
National Customer Care department at 1-800-454-3730.
Coverage of emergent admissions is authorized based on review by a concurrent review nurse. When
the clinical information received meets Milliman criteria, an Amerigroup reference number will be
issued to the hospital. Two requests for additional information will be made over a 48-hour period. If
information is not received within the specified time period, the request will be denied.
If the notification documentation provided is incomplete or inadequate, Amerigroup will not approve
coverage of the request but will notify the hospital to submit the additional necessary documentation.
If the medical director denies coverage of the request, the appropriate denial letter will be mailed to
the hospital, member’s PCP and the member.
Nonemergent Outpatient and Ancillary Services: Precertification and Notification
Requirements
Amerigroup requires precertification for coverage of selected nonemergent outpatient and ancillary
services (see chart below). To ensure timeliness of the authorization, the expectation of the facility
and/or provider is that the following must be provided:
 Member name and ID
 Name, telephone number and fax number of physician performing the elective service
 Name of the facility and telephone number where the service is to be performed
 Date of service
 Member diagnosis
 Name of elective procedure to be performed with CPT-4 code
 Medical information to support requested services (medical information includes current
signs/symptoms, past and current treatment plans, response to treatment plans, and medications)
The table below contains precertification and notification requirement guidelines:
Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
Behavioral Health/
Self-referral to
Covered services include medically necessary mental
Substance Abuse
network provider
health treatment for all members and inpatient
alcohol/drug treatment for pregnant women. Services do
not require referral by a PCP. Emergency behavioral
health care services are covered 24 hours a day, 7 days a
week.
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
Call Amerigroup at 1-800-454-3730 (prompt number 9) or
the Nurse HelpLine at 1-800-600-4441 for immediate
nonemergency assistance.
MMA:
 Inpatient services include up to 28 days in an inpatient
hospital substance abuse treatment program for
pregnant members.
 Nonreform adults have 45 days not exclusive of
medical days and children/adolescents up to age 18
have unlimited inpatient days.
 Outpatient services are covered by Amerigroup.
 Precertification is required for limited therapeutic
behavioral services.
Cardiac
Precertification
Precertification is required for coverage of all services.
Rehabilitation
Chemotherapy
No precertification is required for coverage of
chemotherapy procedures when performed in a
participating facility or provider office, outpatient hospital
or ambulatory surgical center. For information on
coverage of chemotherapy drugs, please see the
Pharmacy section.
Child Health
Check-Up
Chiropractic Services
FL-PM-0024-14
Self-referral
Note: Precertification is required for coverage of
inpatient services.
 MMA: Preventive visits are required once a year for
members from birth through age 20. Use the wellchild screening schedule and document Child Health
Check-Up visits.
 FHK: Preventive visits as needed for members
between the ages of 5 through 18. No copayment is
required.
 MMA: Member may self-refer to a network provider
for a total of 24 visits during a calendar year. Coverage
of a new patient visit is limited to one per provider
per recipient. A new patient is one who has not
received any professional services from a provider or
provider group within three years. Precertification is
not required for a network physician.
 FHK: A $5 copay per visit is required. Coverage is
limited to 24 visits per calendar year.
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
Dermatology Services No precertification  Services considered cosmetic in nature are not
required for
covered.
network provider
 Services related to previous cosmetic procedures are
for Evaluation and
not covered.
Management
 See Diagnostic Testing.
(E&M), testing, and
procedures
Diagnostic Testing
 No precertification is required for routine diagnostic
testing.
 Precertification is required for coverage of MRA, MRI,
CAT scans, nuclear cardiology, PET scans and video
EEG.
 Contact MedSolutions at 1-888-693-3211.
Dialysis
See comments
 No precertification is required for coverage of
outpatient dialysis procedures.
 Precertification is required for medications related to
dialysis treatment.
Disposable Medical
No precertification is required for coverage of disposable
Supplies
medical supplies.
Educational
No notification or precertification is required for
Consultation
coverage.
Emergency Room
Self-referral
 No notification is required for emergency care given in
(ER)
the ER. If emergency care results in admission,
notification to Amerigroup is required within 24 hours
or the next business day.
 FHK: The $10 copay should only be charged:
1. If the urgent care service is taking place in a
hospital ER and
2. If the urgent care service is inappropriate (i.e., the
member’s situation did not meet the definition of
urgent)
Early and Periodic
Self-referral
See Child Health Check-Up
Screening, Diagnosis
and Treatment
(EPSDT)
ENT Services
No precertification  Precertification is required for tonsillectomy and/or
(Otolaryngology)
required for
adenoidectomy, nasal/sinus surgery, and cochlear
network provider
implant surgery and services.
for E&M, testing
 See Diagnostic Testing.
and most
procedures.
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
Family Planning/STD Self-referral
 MMA: Infertility treatment is not covered. Covered
Care
services include information and referral for learning
and counseling, diagnostic procedures, contraceptive
drugs and supplies, and medically needed sterilization
and follow-up care. Services are not covered for a
member under the age of 18 unless married, a parent,
pregnant or will suffer health hazards if services are
not provided.
 FHK: Coverage of family planning is limited to one
annual visit and one supply visit per 90 days.
Gastroenterology
No precertification  Precertification is required for bariatric surgery,
Services
required for
including insertion, removal and/or replacement of
network provider
adjustable gastric restrictive devices and
for E&M, testing
subcutaneous port components and upper
and most
endoscopy.
procedures.
 See Diagnostic Testing.
Gynecology
No precertification Self-referral to network provider.
required for
network provider
in office for E&M,
testing and most
procedures.
Hearing Services
 Precertification for services is not required.
 Members should contact HearUSA at 1-877-664-9353
or see a participating ENT or audiologist. Covered
services include up to 60 hearing aid batteries per
year; subject to medical necessity. Coverage of
newborn screenings for members from birth to 12
months is limited to a maximum of two screenings.
Routine maintenance, batteries, cord or wire
replacement, or cleaning is not covered. There is no
age limit for hearing services.
 FHK: No copay is required.
Home Health Care
Precertification
 Precertification is required for coverage of all services.
 Medicaid and FHK members may contact Univita at
1-866-887-7667 for benefit information.
 FHK: $5 copay per visit is required. Coverage is limited
to skilled nursing services.
Hospice Care
 Hospice is a covered benefit for MMA and does not
require precertification.
 Notification is required for coverage of inpatient
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
hospice services.
 FHK: Precertification is required for coverage of
inpatient hospice services.
 See Home Health Care.
Hospital
Precertification
 Precertification is required for coverage of an elective
Admission
admission.
 Notification is required for coverage of emergency
and obstetric admissions within 24 hours or the next
business day.
 To be covered, preadmission testing must be
performed by an Amerigroup-preferred lab vendor or
network facility outpatient department. See provider
referral directory for a complete listing of
participating vendors.
MMA: Non-pregnant members age 21 and older are
covered for up to 45 inpatient days and up to 365 days of
emergency inpatient care. Members under age 21 are
covered for up to 365 days of health-related inpatient
care. Twenty-eight inpatient hospital days in an inpatient
hospital substance abuse treatment program for pregnant
substance abusers who meet ISD Criteria with Florida
Medicaid modifications, as specified in InterQual Level of
Care Acute Criteria-Pediatric and/or InterQual Level of
Acute Criteria-Adult for use in screening cases admitted
to
rehabilitative
hospitals
and
CON-approved
rehabilitative units in acute care hospitals.
 FHK: Amerigroup case managers will coordinate
services that are medically necessary. Covered
services include 15 days per contract year for
preapproved rehabilitation and physical therapy stays.
No copay is required.
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
Laboratory Services
 Precertification is required for all laboratory services
(Outpatient)
furnished by non‐network providers except hospital
laboratory services in the event of an emergency
medical condition.
 All laboratory tests must be submitted to Quest
Diagnostics or LabCorp, the preferred lab providers for all
Amerigroup members. Contact Quest or LabCorp at
the numbers below to receive a Quest or LabCorp
specimen drop box.
 For more information, testing solutions and services
or to set up an account, contact either:
- Quest Diagnostics: 1-866-MY-QUEST (1-866-6978378)
- LabCorp: 1-800-345-4363
Neurology
No precertification  Precertification is required for neurosurgery, spinal
required for
fusion and artificial intervertebral disc surgery.
network provider
 See Diagnostic Testing.
for E&M and most
testing
Observation
 No precertification or notification required for innetwork observation.
 If observation results in admission, notification to
Amerigroup is required within 24 hours or the next
business day.
 If admission occurs, all charges for observation
services roll up into the admission.
Obstetrical Care
 Member may self-refer to a network OB/GYN
provider.
 No precertification/PCP referral is required for
coverage of obstetrical services, including obstetrical
visits, diagnostic tests and laboratory services when
performed by a participating provider. This includes
prenatal office visits (10 for normal pregnancy or 14
for high-risk pregnancy), postpartum office visits,
routine ultrasounds and lab work.
 No precertification is required for coverage of labor
and delivery.
 Notification to Amerigroup is required at the FIRST
prenatal visit.
 Notification is required for coverage of emergency
and obstetric admissions within 24 hours or the next
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
business day.
 FHK: Notification is required. We cover 48 hours postdelivery for vaginal births and 96 hours post-delivery
for C-section deliveries.
Ophthalmology
See comments
 Precertification must be obtained through eyeQuest
(1-888-696-9551) from a participating eyeQuest
optometrist. See Vision Care. There is no age limit for
vision services.
 Examination, diagnosis, treatment, and management
of ocular and adnexal pathology
 Visual examinations to determine the need for
eyeglasses
 Members age 21 years and older are covered for an
extra $100 for contact lenses and contact lens
services, as medically necessary.
 Visual services include the medically necessary
provision of optical services and supplies such as
eyeglasses, prosthetic eyes, and contact lenses. The
fitting, dispensing, and adjusting of eyeglasses, and
eyeglass repair services are also covered.
Oral Maxillofacial
See Plastic/Cosmetic/Reconstructive Surgery.
Out-of-Area/Out-of- Precertification
Precertification is required for any out-of-area/out-ofNetwork Care
network care except for coverage of emergency care
(including self-referral) and OB care.
Outpatient/
Precertification
Precertification requirements based on the service
Ambulatory Surgery
performed.
Pain Management
Precertification
 No precertification is required for E&M services.
 Precertification is required for all other services.
 See Diagnostic Testing.
Pharmacy
 The pharmacy benefit covers medically necessary
prescriptions prescribed by a licensed provider.
Exceptions and restrictions exist as the benefit is
provided under a closed formulary/Preferred Drug List
(PDL). Please refer to the PDL on our provider website
for the preferred products within therapeutic
categories and requirements around generics, prior
authorization step therapy, quantity edits and the
prior authorization process. Quantity and day supply
limits apply.
 MMA: Covered prescription drugs at no cost. Non
Reform: OTC drug benefit is subject to $25 per
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
household per month.
 FHK: $5 per prescription for up to a 31-day supply.
OTC drug benefit does not exceed $10 per family per
month.
Physiatry
Precertification
 Precertification is required for coverage of all services
and procedures related to pain management.
 See Diagnostic Testing.
Physical Medicine
Precertification
 Precertification is required for coverage of all services
and Rehabilitation
and procedures related to pain management.
 See Diagnostic Testing.
Plastic/Cosmetic/
No precertification  All other services require precertification for
Reconstructive
required for
coverage.
Surgery (including
network provider
 Services considered cosmetic in nature are not
Oral Maxillofacial
for E&M
covered.
Services)
 Services related to previous cosmetic procedures are
not covered (e.g., scar revision, keloid removal
resulting from pierced ears).
 Reduction mammoplasty requires medical director’s
review and approval.
 No precertification is required for coverage of oral
maxillofacial E&M services.
 Precertification is required for coverage of trauma to
the teeth and oral maxillofacial medical and surgical
conditions including TMJ.
Podiatry
No precertification Coverage includes:
required for
 Open access
network provider
 One podiatrist-recipient contact per day, not to
in office for E&M,
exceed two per month except for emergencies
testing and most
 One long-term care facility service per month per
procedures
recipient except for emergencies
 One new patient E&M service per recipient every
three years
See Diagnostic Testing
Primary Care
Self-referral
 MMA: Covered services include preventive,
Provider (PCP)
diagnostic, therapeutic palliative care or treatment of
Services
an illness or disease. Provider services do not include
nonclinically proven procedures or cosmetic surgery.
 FHK: No copay is required.
Radiation Therapy
No precertification is required for coverage of radiation
therapy procedures when performed in the following
outpatient settings by a network facility or provider:
FL-PM-0024-14
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
office, outpatient hospital and ambulatory surgery center.
Radiology
See Diagnostic Testing.
Rehabilitation
Precertification
 MMA: No precertification is required for initial
Therapy
evaluation. Covered services include evaluation and
(Short-term): OT, PT,
treatment to prevent or correct physical deficits.
RT and ST
Coverage limitations:
 One initial evaluation per member per provider
 One re-evaluation every six months per member per
provider
 Medically necessary therapy services are covered for
members under age 21 and for members over 21 only
if services are provided in an outpatient hospital
setting
 Home PT and OT: All members must be referred to
Univita for these services. (Note: Manatee Rural
Health is excluded from this requirement.)
 ST: Refer members to an in-network provider.
 MMA: For members over 21 years of age, limitations
apply
 FHK: Outpatient coverage is limited to 24 sessions
within a 60-day period per incident. The 60-day
coverage period begins with the first visit. A $5 copay
is required for each office visit.
 Please call Amerigroup for precertification at
1-800-454-3730.
Respite Care Services Precertification
If medically needed, members can get an initial home
health visit by a registered nurse and eight follow-up
visits (each lasting four hours) by an aide. This benefit
includes a maximum of 16 hours per month and 32 hours
per year.
Sleep Study
Precertification
Precertification is required for sleep studies.
Sterilization
 Sterilization services are a covered benefit for
members 21 and older.
 No precertification or notification is required for
coverage of sterilization procedures, including tubal
ligation and vasectomy.
 Sterilization consent form is required for claims
submission.
 Reversal of sterilization is not a covered benefit.
Transplant Services
Precertification
Precertification is required for coverage.
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
Transportation
 MMA: Members may contact LogistiCare
(1-866-372-9794) for nonemergent transportation or
reference their member handbooks.
 FHK: Precertification is required for fixed-wing
transportation. A $10 copay is required per trip for
emergency services only. Nonemergent
transportation services are not covered.
Urgent Care Center
 No notification or precertification is required for a
network facility.
 FHK: The $10 copay should only be charged:
- If the urgent care service is taking place in a hospital
ER and
- If the urgent care service is inappropriate (i.e., the
member’s situation did not meet the definition of
urgent)
Vision Care (Medical) Precertification
 See Ophthalmology.
 FHK: $5 copay per specialist visit is required.
Vision Care (Routine) Self-referral
 Services include eye exams plus certain glasses and
contact lenses, if medically needed. Contact eyeQuest
at 1-888-696-9551. There is no age limit for vision
services.
 MMA (TANF and SSI): Members ages 21 years and
older are covered for an extra $100 for contact lenses
and contact lens services, as medically necessary.
 FHK: Covered services include an eye exam plus
corrective lenses and frames if medically needed.
 No copay is required for routine eye exams provided
by the PCP.
 $5 copay per specialist visit is required.
 $10 copay for corrective lenses is required.
Well-woman Exam
Self-referral
 Well-woman exams are covered once every 365 days
by either PCP or a network GYN. Services include
exam, physical, blood work, routine lab, STD screening
and Pap smear, and mammogram (one baseline at age
35 or older, one per year at age 40 and older).
 FHK: No copay is required by member.
Revenue (RV) Codes
To the extent the following services are covered benefits,
precertification or notification is required for all services
billed with the following revenue codes:
 All Inpatient and Behavioral Health Accommodations
 0023 – Home Health Prospective Payment System
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Amerigroup Precertification/Notification Coverage Guidelines
Florida MMA/MediKids Program and Florida Healthy Kids (FHK) Program
SERVICE
REQUIREMENT
COMMENTS
 0240 through 0249 – All-inclusive Ancillary Psychiatric
 0570 through 0572, 0579 – Home Health Aide
 0632 – Pharmacy Multiple Source
 0901, 0905 through 0907, 0913, 0917 – Behavioral
Health Treatment Services
 0944 through 0945 – Other Therapeutic Services
 0961 – Psychiatric Professional Fees
 3101 through 3109 – Adult day care and foster care
For services that require precertification, Amerigroup uses Interqual, Florida Medicaid Guidelines,
WellPoint Medical Policies, and WellPoint Clinical UM Guidelines.
Amerigroup is staffed with clinical professionals who coordinate services provided to members and are
available 24 hours a day, 7 days a week to accept precertification requests. When a request for medical
services is received from the physician by fax, the precertification assistant will verify eligibility and
benefits, which will then be forwarded to the nurse reviewer.
The nurse will review the request and the supporting medical documentation to determine the medical
appropriateness of diagnostic and therapeutic procedures. When appropriate, the nurse will assist the
physician in identifying alternatives for health care delivery as supported by the medical director.
When the clinical information received meets medical necessity criteria, an Amerigroup reference
number will be issued to the referring physician.
If the request is a stat/urgent request (i.e., expedited service authorizations), the decision will be made
within two business days.
If the precertification documentation is incomplete or inadequate, the nurse will not approve coverage
of the request but will instead notify the provider to submit the additional necessary documentation.
Two requests for additional information will be made over a 48-hour period. If information is not
received within the specified time period, the request will be denied.
If the medical director denies the request for coverage, the appropriate notice of proposed action will
be mailed to the requesting provider, the member’s PCP, the facility and the member.
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Inpatient Reviews
Inpatient Admission Review
All inpatient hospital admissions, including urgent and emergent admissions, will be reviewed within
24 hours. The Amerigroup utilization review clinician determines the member’s medical status through
communication with the hospital’s utilization review department. Appropriateness of stay is
documented and concurrent review is initiated. Cases may be referred to the medical director, who
renders a decision regarding the coverage of hospitalization. Diagnoses meeting specific criteria are
referred to the medical director for possible coordination by the Care Management program.
Inpatient Concurrent Review
Each network hospital will have an assigned Utilization Management (UM) clinician. Each UM clinician
will conduct a concurrent review of the hospital medical record at the hospital or by telephone to
determine the authorization of coverage for a continued stay.
When an Amerigroup UM clinician reviews the medical record at the hospital, he or she also attempts
to meet with the member and family to discuss any discharge planning needs and verify that the
member or family is aware of the PCP’s name, address and telephone number. The UM clinician will
conduct continued stay reviews daily and review discharge plans unless the patient’s condition is such
that it is unlikely to change within the upcoming 24 hours and discharge planning needs cannot be
determined.
When the clinical information received meets medical necessity criteria, approved days will be
communicated to the hospital for the continued stay. The request for the clinical information needed
will be communicated to the designated department within the hospital. Amerigroup asks that the
hospital reviewer provide only the necessary information being requested and not provide the entire
medical record.
If the discharge is approved, the Amerigroup UM clinician will help coordinate discharge planning
needs with the hospital utilization review staff and attending physician. The attending physician is
expected to coordinate with the member’s PCP regarding follow-up care after discharge. The PCP is
responsible for contacting the member to schedule all necessary follow-up care. In the case of a
behavioral health discharge, the attending physician is responsible for ensuring that the member has
secured an appointment for a follow-up visit with a behavioral health provider to occur within seven
calendar days of discharge.
Amerigroup will authorize covered length of stay one day at a time based on the clinical information
that supports the continued stay. Exceptions to the one-day length of stay authorization are made for
confinements when the severity of the illness and subsequent course of treatment is likely to be
several days or is predetermined by state law. Examples of confinement and/or treatment include the
following: ICU, CCU, behavioral health rehabilitation and C-section or vaginal deliveries. Exceptions are
made by the medical director.
If, based upon appropriate criteria and after attempts to speak to the attending physician, the medical
director denies coverage for an inpatient stay request, the appropriate notice of action will be mailed
to the hospital, the member’s PCP and the member.
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Discharge Planning
Discharge planning is designed to assist the provider in the coordination of the member’s discharge
when acute care (i.e., hospitalization) is no longer necessary.
When long-term care is necessary, Amerigroup works with the provider to plan the member’s
discharge to an appropriate setting for extended services. These services can often be delivered in a
nonhospital facility, such as a:
 Hospice facility
 Convalescent facility
 Home health care program (e.g., home IV antibiotics)
When the provider identifies medically necessary and appropriate services for the member, we will
assist the provider and the discharge planner in providing a timely and effective transfer to the next
appropriate level of care.
Discharge plan authorizations follow UniCare Clinical UM Guidelines. Authorizations include, but are
not limited to, home health, durable medical equipment, pharmacy, follow-up visits to practitioners or
outpatient procedures.
Confidentiality of Information
Utilization Management (UM), case management, disease management, discharge planning, quality
management and claims payment activities are designed to ensure that patient-specific information,
particularly protected health information obtained during review, is kept confidential in accordance
with applicable laws, including the HIPAA. Information is used for the purposes defined above.
Information is shared only with entities who have the authority to receive such information and only
with those individuals who need access to such information in order to conduct UM and related
processes.
Emergency Services
Amerigroup provides a 24 hours a day, 7 days a week Nurse HelpLine service with clinical staff to
provide triage advice and referral and, if necessary, to make arrangements for treatment of the
member. The staff has access to qualified behavioral health professionals to assess behavioral health
emergencies.
Amerigroup does not discourage members from using the 911 emergency system or deny access to
emergency services. Emergency services are provided to members without requiring precertification.
Any hospital or provider calling for an authorization for emergency services will be granted one
immediately upon request. Emergency services coverage includes services that are needed to evaluate
or stabilize an emergency medical condition. Criteria used to define an emergency medical condition
are consistent with the prudent layperson standard and comply with federal and state requirements.
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An emergency medical condition is defined as a physical or behavioral condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses
an average knowledge of health and medicine could reasonably expect the absence of immediate
medical attention to result in the following: (1) placing the health of the individual (or, with respect to
a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (2) serious
impairment to bodily functions or (3) serious dysfunction of any bodily organ or part.
Emergency response is coordinated with community services, including the police, fire and EMS
departments, juvenile probation, the judicial system, child protective services, chemical dependency,
and local mental health authorities, if applicable.
When a member seeks emergency services at a hospital, the determination as to whether the need for
those services exists will be made for purposes of treatment by a physician licensed to practice
medicine or, to the extent permitted by applicable law, by other appropriately licensed personnel
under the supervision of, or in collaboration with, a physician licensed to practice medicine. The
physician or other appropriate personnel will indicate in the member’s chart the results of the
emergency medical screening examination. Amerigroup will compensate the provider for the
screening, evaluations and examination that are reasonable and calculated to assist the health care
provider in determining whether or not the patient’s condition is an emergency medical condition.
If there is concern surrounding the transfer of a patient (i.e., whether the patient is stable enough for
discharge or transfer or whether the medical benefits of an unstable transfer outweigh the risks), the
judgment of the attending physician(s) actually caring for the member at the treating facility prevails
and is binding on Amerigroup. If the emergency department is unable to stabilize and release the
member, Amerigroup will assist in coordination of the inpatient admission, regardless of whether the
hospital is network or non-network. All transfers from non-network to network facilities are to be
conducted only after the member is medically stable and the facility is capable of rendering the
required level of care.
If the member is admitted, the Amerigroup concurrent review nurse will implement the concurrent
review process to ensure coordination of care.
Urgent Care
Amerigroup requires its members to contact their PCP in situations where urgent, unscheduled care is
necessary. Precertification with Amerigroup is not required for a member to access a participating
urgent care center.
FL-PM-0024-14
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QUALITY MANAGEMENT
Quality Management Program
Overview
Amerigroup maintains a comprehensive Quality Management (QM) Program to objectively monitor
and systematically evaluate the care and service provided to members. The scope and content of the
program reflects the demographic and epidemiological needs of the population served. Members and
providers have opportunities to make recommendations for areas of improvement. The QM Program
goals and outcomes are available, upon request, to providers and members. Studies are planned across
the continuum of care and service with ongoing proactive evaluation and refinement of the program.
The initial program development was based on a review of the needs of the population served.
Systematic re-evaluation of the needs of the plan’s specific population occurs on an annual basis. This
includes not only age/sex distribution, but also a review of utilization data — inpatient,
emergent/urgent care and office visits by type, cost and volume. This information is used to define
areas that are high-volume or that are problem-prone.
There is a comprehensive committee structure in place with oversight from the Amerigroup governing
body. Not only are the traditional Medical Advisory Committee (MAC) and Credentialing Committee in
place, but a Community/Member Advisory Committee and Health Education Advisory Committee are
also integral components of the Quality Management Committee (QMC) structure.
Quality of Care
All physicians, advanced registered nurse practitioners and physician assistants are evaluated for
compliance with pre-established standards as described in the Amerigroup credentialing program.
Review standards are based on medical community standards, external regulatory and accrediting
agencies requirements, and contractual compliance.
Reviews are accomplished by QM coordinators and associate professionals who strive to develop
relationships with providers and hospitals that will positively impact the quality of care and services
provided to our members.
Results are submitted to the Amerigroup QM department and incorporated into a profile.
The Amerigroup quality program includes review of quality-of-care issues identified for all care
settings. QM staff use member complaints, reported adverse events and other information to evaluate
the quality of service and care provided to our members.
Use of performance data
Practitioners and providers must allow Amerigroup to use performance data in cooperation with our
quality improvement program and activities.
Quality Management Committee
The purpose of the QMC is to maintain quality as a cornerstone of Amerigroup culture and to be an
instrument of change through demonstrable improvement in care and service.
The QMC’s responsibilities are to:
 Establish strategic direction and monitor and support implementation of the QM Program
 Establish processes and structure that ensure accreditation compliance
 Analyze, review and make recommendations regarding the planning, implementation,
measurement and outcomes of clinical/service quality improvement studies
 Address and resolve any problems/issues identified but not included in a process improvement
program
 Coordinate communication of QM activities throughout the health plans
 Review and analyze Healthcare Effectiveness Data and Information Set and Consumer Assessment
of Healthcare Providers and Systems data and action plans for improvement
 Review, monitor and evaluate program compliance against Amerigroup, state, federal and
accreditation standards
 Review and approve the annual QM Program description and work plan
 Provide oversight and review of delegated services
 Provide oversight and review of operational indicators
 Assure interdepartmental collaboration, coordination and communication of quality improvement
activities
 Measure compliance to medical and behavioral health practice guidelines
 Monitor continuity of care between medical and behavioral health services
 Monitor accessibility and availability with cultural assessment
 Make information publicly available to members and practitioners about our actions to improve
patient safety
 Make information available about our quality improvement program to members and
practitioners; members and providers can request the program by calling Customer Service
 Assure practitioner involvement through direct input from our MAC or other mechanisms that
allow practitioner involvement
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- - 76 - -
Medical Advisory Committee
The MAC has multiple purposes. The MAC assesses levels and quality of care provided to members and
recommends, evaluates and monitors standards of care. The MAC identifies opportunities to improve
services and clinical performance by establishing, reviewing and updating clinical practice guidelines
based on review of demographics and epidemiologic information to target high-volume, high-risk and
problem-prone conditions. The MAC oversees the peer review process that provides a systematic
approach for the monitoring of quality and the appropriateness of care. The MAC conducts a
systematic process for network maintenance through the credentialing/recredentialing process. The
MAC advises health plan administration in any aspect of health plan policy or operation affecting
network providers or members. The MAC approves and provides oversight of the peer review process,
the QM Program and the Utilization Review Program. It oversees and makes recommendations
regarding health promotion activities.
The MAC’s responsibilities are to:
 Utilize an ongoing peer review system to assess levels of care and quality of care provided
 Monitor practice patterns in order to identify risk prevention activities and the appropriateness of
care
 Review, provide input and approve evidence-based clinical protocols and guidelines to facilitate the
delivery of quality care and appropriate resource utilization
 Review clinical study designs and results
 Develop and approve action plans and recommendations regarding clinical quality improvement
studies
 Consider and act in regard to physician sanctions
 Review, provide input for, and approve policies and procedures for credentialing/recredentialing,
QM, utilization management and disease/case management
 Review and provide feedback regarding new technologies
 Oversee the compliance of delegated services
Provider Orientation and Education
QM coordinators are available to provide a thorough orientation to Amerigroup review standards.
Educational sessions can be scheduled at a provider’s convenience. The QM staff is also available to
furnish providers with a thorough explanation of review findings during an exit conference on the day
of the review. If a provider’s schedule does not allow for sufficient time on the day of the review, a
follow-up appointment can be scheduled. Experience has taught that provider participation in
orientation and education sessions helps improve standards’ compliance and, therefore, decreases the
frequency for required reviews.
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Medical Record Documentation Review Standards
Administrative Component
MEDICAL RECORD DOCUMENTATION STANDARDS
For Primary Care Providers
ELEMENTS & REFERENCES
1. Record is organized and legible
AAAHC, Std 6, G, M
AHCA, 20.13, a (2)
2. Member identification on file
AHCA, 20.13, a (1)
3. Personal biographical data
AHCA, 20.13, a (1)
4. Primary language and
translation
AAAHC Std 4, H
AHCA, 20.13, a (13), (14)
5. Advance directives advisement
AHCA, 20.13, a (15)
FL Statute 765.110
FL-PM-0024-14
GUIDELINES
Records are fastened and maintained in detail with contents
organized in a logical, consistent manner to facilitate
information retrieval.

There is an individual record for each member.

The record must be legible.
Record legibility is determined by the Amerigroup reviewer; a
record is scored as illegible when the reviewer cannot
decipher documentation sufficiently to score the record.
A copy of the Amerigroup membership card on file or in the
medical record or a written office policy regarding verification
of member eligibility before rendering service. Use of the
current Amerigroup membership list is acceptable for
eligibility verification.
Required information: name, member identification number,
date of birth, sex, address and telephone number. For
pediatric members (under 21 years old), the name of a parent
or a legal guardian is required.

All records must reflect the member’s primary spoken
language and translation needs to include services for the
deaf or hard of hearing. Records must identify members
needing communication assistance in the delivery of
health care service.

Documentation may be by the member (i.e., included on a
patient history form or by the provider or office staff).

When the member is an infant or young child,
documentation of the primary language spoken by others
in the home is required.

If English is the primary language, this must be
documented.
All records for members 21 years and older must contain:

Documentation that the member was provided written
information concerning the member’s rights regarding
advanced directives (written instructions for living will or
durable power of attorney).

Documentation whether or not the member has executed
an advance directive. When an advance directive exists, a
copy must be maintained in the record.
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ELEMENTS & REFERENCES
6. Patient identification on
each page
Amerigroup Florida
7. Entries dated and signed
AAAHC, Std 6, K1, 8
AHCA, 20.13, a (4), (8)
FL Regulation 64B8-30.012
8. Requested tests accomplished
and filed
AAAHC, Std 4, D5, 7, 8; Std 6H
AHCA 20.13, a (5)
9. Follow-up of missed and
cancelled appointments
AAAHC, Std 6, K(9)
FL-PM-0024-14
GUIDELINES
Patient first and last name and/or an identification number
are on ALL pages, reports and documents in the record. Pages
that are used on both sides require identification on each
side.

All entries must be signed and dated with month, day and
year. This applies to all clinical entries such as history
forms, progress notes, triage documentation,
immunization administration, referral forms, etc.

All entries must contain author identification. Signatures
must include professional status when applicable (M.D.,
D.O., ARNP, P.A., R.N., LPN and M.A.). Applies to both
licensed and nonlicensed personnel.

All physician assistant signatures must be reviewed,
cosigned and dated by a supervising physician within
seven days. ARNP notes do not require cosigning.
Evidence is in the record to support that ordered tests and
referrals were accomplished. Acceptable documentation
includes test results/consult reports filed in record and
telephone results documented in progress notes or on an
office form designed for that purpose. Attempts to obtain
reports should be documented.

Patient noncompliance and associated risks must be
documented when applicable.

Results are to be filed in the record:
- Consults: within six weeks of the date the PCP initiated
the request or four weeks from the date of the
consult. It is the PCP’s responsibility to obtain
consultant reports.
- Laboratory tests: Routine — within two weeks of the
date ordered/planned in the PCP records. Nonroutine
— (endocrine studies, genetic mapping, tuberculosis
cultures, fungal cultures, etc.) — within two weeks of
the date ordered/planned in the PCP progress notes.
- Radiographic studies: within two weeks of the date
noted in the PCP plan.
Processes are in place to obtain and follow up on consultant
visits and diagnostic studies (e.g., tickler files, logbook,
computer log, etc.).
Documentation of follow-up for missed and cancelled
appointments is required.
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General Medical Care
MEDICAL RECORD DOCUMENTATION REVIEW STANDARDS
For Primary Care Providers
ELEMENTS & REFERENCES
1. Allergies noted
AAAHC, Std 6J
AHCA, 20.13, a (3)
2. Problem list maintained
AAAHC, Std 6I
AHCA, 20.13, a (3)
3. Medication profile is
maintained
AHCA, 20.13, a (3)
4. Health history documented
AAAHC, Std 4, D3; Std 6I
AAP Recommendations
AHCA, 20.13, a (3)
AHCA CLH, pages 2-5, 2-6
AHCA CH CLH, pages 2-2, 2-6
FL-PM-0024-14
GUIDELINES
All patient allergies are prominently and uniformly noted in
the record. When there are no known allergies, this is noted
prominently and uniformly in the record.
A problem list is maintained for each patient. The list identifies
chronic and significant illnesses, diagnoses, medical conditions
and significant surgical procedures based on the history and
physical. If a summary of significant surgical procedures is
found elsewhere (i.e., the H&P and is prominently and
uniformly displayed), it is not required to repeat on the
problems list. Documentation of the problem list in the
progress notes alone meets standards only if the complete list
is documented at each visit.
A medication profile for all chronic medications is clearly
documented on a medication list; dosage is required.
Documentation of medications for acute illnesses may be
documented in the progress notes alone; they must reflect the
start and stop dates.

A thorough health history must be documented in the
record at least once. This should be accomplished during
the first visit.

A periodic interval history or update is required with each
preventive health visit as a minimum.

Components of the health history include:
- Current medications
- Chronic/past illnesses/diagnoses/problems (including
childhood diseases)
- Hospitalizations and significant surgical procedures
- Transfusion of blood products
- Family history
- Social/behavioral history
- Review/inventory of systems
- Required for infants 2 months and younger: a prenatal,
delivery and neonatal history (recommended for all
children)
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ELEMENTS & REFERENCES
5. Tobacco/alcohol/drug use
AAP Recommendations
AHCA, 20.13, a (11)
AHCA CH CLH, pages 2-7
6. Subjective complaint recorded
AAAHC, Std 6K, 2
AHCA, 20.13, a (5)
7. Objective findings
AAAHC, 6K, 3
AHCA, 20.13, a (5)
7. Vital signs recorded
Amerigroup
9. Working diagnosis
AAAHC, Std 4, D3; Std 6, K4
AHCA, 20.13, a (5)
AHCA CH CLH, pages 2-2
10. Plan of care documented
AAAHC, Std 4, D4; Std 6K5,6,7
AHCA, 20.13, a (6), (7), (9)
AHCA CH CLH, pages 2-2
GUIDELINES
Records for members ages 8 years old or older must contain
documentation regarding the member’s:

Tobacco use and exposure to secondhand smoke

Alcohol use

Drug use/abuse (street drugs, inhalants, prescription drug
abuse)
This requires assessment of the member’s actual use/abuse of
these substances. Education regarding the risks associated with
such use is addressed with age-specific preventive health
standards and anticipatory guidance.
The chief complaint or reason for the visit, as told by the
patient or family member, must be recorded.
Objective findings include at least the physical findings relative
to the subjective complaint.
Anytime patient refusal is documented. Education regarding
the risk associated with the refusal must be documented.
Vital signs are required as appropriate for the chief complaint.
The rationale for which a plan is formulated and the diagnosis
or clinical impression is required. Appropriateness is based on
the findings in the history and physical.
All entries must indicate diagnostic tests, consultations and
treatments administered or prescribed. Dispositions,
recommendations, evidence of follow-up and outcomes of
services must be documented. The plan is consistent with the
working diagnosis. When treatment is for a chronic condition,
there is evidence of continued care.
11. Follow up of acute or chronic
Documentation of follow-up care is present for:
problems and high-risk issues  Unresolved problems from previous visits that are
addressed in subsequent visits  addressed in subsequent visits.
AAAHC, Std 4, D8

Follow-up of high-risk issues that are identified in the
history and physical or at subsequent visits.
12. Patient teaching/instructions
Documentation of patient education and counseling pertinent
AAAHC, Std 4, D1; Std 6Q
to the subjective complaint, personal and family history, newly
AHCA, 20.13, a (9)
prescribed medications, treatment and/or therapy, diagnosis,
and plan is required.
Patient noncompliance and/or refusal to follow diagnostic or
treatment plans must be accompanied by documented
instruction regarding the risk associated with the
noncompliance.
FL-PM-0024-14
- - 81 - -
ELEMENTS & REFERENCES
13. Follow-up requirements
documented
AHCA, 20.13, a (9)
Amerigroup Florida
14. Emergency care documented
AHCA, 20.13.a (12)
AAAHC, Std 6, O
15. Hospital care documented
AHCA, 20.13.a (12)
AAAHC, Std 6, O
16. All reports initialed and dated
by PCP
AAAHC, Std 4, D8; Std 6H
GUIDELINES
A specific time for return (i.e., the next patient visit) is noted in
days, weeks, months, PRN, etc.
Information regarding emergency care is recorded in the
record. A copy of the emergency room record or a progress
note reflecting the PCP’s discussion with the hospital or
treating provider is required.
Information regarding hospitalizations is recorded in the
record. A copy of the discharge summary or a progress note
reflecting the PCP’s discussion with the hospital or treating
physician is acceptable.
Consultation, lab and imaging reports filed in the record are
initialed and dated by a provider to signify review.
Processes must be in place for patient notification and followup of abnormal diagnostic studies.
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- - 82 - -
Adult
MEDICAL RECORD DOCUMENTATION REVIEW STANDARDS
For Primary Care Providers
PCPs are responsible for contacting new members and conducting preventive health care within 90
days of enrollment. Member contacts and attempted contacts must be documented.
ELEMENTS
1. Risk screening
AHCA CLH, pages 2-6
USPSTF
2. Interval history
AHCA CLH, pages 2-5, 2-6
3. Immunizations
AHCA, 20.13 a (10)
USPSTF
a. Influenza
b. Tetanus (TD booster)
c. Pneumococcal
4. Height and weight
AHCA CLH, pages 2-6
USPSTF
5. Vital signs
AHCA CLH, pages 2-6
USPSTF
FL-PM-0024-14
GUIDELINES
Screening to identify high-risk individuals and assessing family,
medical and social history is required. Screening for the following
risks are required as a minimum: cardiovascular disease, hepatitis,
HIV/AIDS, STDs other than HIV/AIDS, and TB.
Appropriate interventions and follow-up for high-risk patients, or the
rationale for no intervention, must be documented.
Interval histories are required with preventive health care. Changes
in medical, emotional and social status are documented.
Age-appropriate immunizations are documented and current. If
immunization status is not current, this is documented with a catchup plan. It is not sufficient to document up to date, documentation
of a date or year is necessary.
a. Influenza: annually beginning at age 65 and all pregnant women
b. TD booster: every 10 years if completed five-dose series in
childhood beginning at age 18
c. Pneumococcal: age 65 and older at once
If vaccinated with pneumococcal vaccine when under 65 and it
has been five years since the vaccination, revaccinate at 65 or
after five years
Documented height and weight required for all preventive health
care visits and at least:

Every five years for ages 21 to 40

Every two years beginning at age 41
Pulse and blood pressure are required for all preventive health care
visits and at least:

Every five years for ages 21 to 40

Every two years beginning at age 41
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ELEMENTS
6. Physical exam
AHCA CLH, pages 2-6
7. Urinalysis testing
AHCA CLH, pages 2-6
8. Hemoglobin and/or
hematocrit
AHCA CLH, pages 2-6
9. Cholesterol screening
USPSTF
Amerigroup Florida
10. Visual acuity testing
AHCA CLH, pages 2-6
11. Hearing screening
AHCA CLH, pages 2-6
FL-PM-0024-14
GUIDELINES
Appropriate evaluation for inclusion in the baseline physical
examination of an asymptomatic adult are:

General appearance

Skin

Gums/dental/oral

Eyes/ears/nose/throat

Neck/thyroid

Chest/lungs

Cardiovascular

Breasts

Abdomen/GI

Pelvic

Genital/urinary

Rectal

Extremities

Musculoskeletal

Neurological

Lymphatic
If noncompliance or refusal is documented, the risk associated with
the noncompliance must be documented.
Urinalysis documented; as a minimum, dipstick for blood, sugar and
acetone. Required per adult health screening guidelines.

Every five years for ages 21 to 40

Every two years beginning at age 41
Documentation of a hemoglobin or hematocrit is required per adult
health screening guidelines.

Every five years for ages 21 to 40

Every two years beginning at age 41
Screening required every five years for:

Men beginning at age 35

Women beginning at age 45
Screening must include all of the following:

Total Cholesterol (TC)

High-density Lipoprotein Cholesterol (HDL-C)

Low-density Lipoprotein Cholesterol (LCL-C)
Visual acuity testing; at a minimum, documents the patient’s ability
to see at 20 feet.

Every five years for ages 21 to 40

Every two years beginning at age 41
Hearing screening; at a minimum, must include documentation of a
patient’s ability to hear by air conduction.

Beginning at age 65
- - 84 - -
ELEMENTS
12. Colorectal cancer
screening
ACS
AHCA CLH, pages 2-7
USPSTF
13. Cervical cancer screening
AHCA CLH, pages 2-7
USPSTF
14. Chlamydia screening
AHCA CLH, pages 2-7
USPSTF
15. Mammography
AHCA CLH, pages 2-7
USPSTF
16. Prostate cancer
screening
AHCA CLH, pages 2-7
USPSTF
17. Education/anticipatory
guidance
Preventive Services Task
Force
FL-PM-0024-14
GUIDELINES
Colorectal cancer screening beginning at age 50 may be
accomplished by any of the following:

Colonoscopy, every 10 years

Flexible sigmoidoscopy, every five years

Double-contrast barium enema, every five years

Annual Fecal Occult Blood Test (FOBT)
Annual Pap smears for cervical cancer screening are required for all
sexually active females, regardless of age, and all females ages 18
and older.
Screening for chlamydia for all sexually active females under age 26
is required.
Required for females as appropriate for age:

Baseline between ages 35 and 40

Annually after age 40
Documentation of a biannual prostate exam and Prostate-Specific
Antigen (PSA) testing beginning at age 50 for all males.
Health education and guidance must be documented. Educational
needs are based on risk factors identified through personal and
family medical history and social history and current practices.
- - 85 - -
Adolescent Wellness Care
MEDICAL RECORD DOCUMENTATION REVIEW STANDARDS
For Primary Care Providers
ELEMENTS
1. Well-child screening
schedule maintained
AAP
AHCA, 10.8.1a
AHCA CH CLH, pages 2-2, 2-4,
2-5
Provider Manual
2. Interval history
AAP
AHCA, 10.8.1a
AHCA CH CLH, pages 2-6
3. Risk screening
AHAC CH CLH, pages 2-6, 2-7,
2-15
USPSTF
4. TB risk screening
AAP
AHCA CH CLH, pages 2-15, 2-16
Pediatric Red Book
5. Hemoglobin and/or hematocrit
testing
AAP Recommendations 2000
AHCA, 10.8.1a
AHCA CH CLH, 2-13
6. Urinalysis
AAP
AHCA CH CLH, pages 2-16
FL-PM-0024-14
GUIDELINES
Periodic comprehensive, preventive health exam visits are
accomplished in accordance with the American Academy of
Pediatrics and Agency for Health Care Administration. For
adolescents, well-child exams are required annually from ages
11 through 20.
PCPs are responsible for contacting and scheduling or
conducting preventive health screenings for members within
90 days of assignment to their panel. Member contacts and
attempted contacts are documented in the medical record.
An interval history is required at each well visit. Changes in
medical, emotional and social status are documented.
Screening to identify high-risk individuals and assessing family,
medical and social history is required. If high-risk indicators
are present, appropriate follow-up or a rationale for no
intervention is documented. See Amerigroup Florida’s
High-Risk Intervention Guide as a summary of some of the
U.S. Preventive Services Task Force recommendations.
Screening for TB risk factors is required.

Adolescents who have no risk factors and live in low-TBprevalent communities do not need skin (Mantoux)
testing. But the record must reflect an assessment of the
risk factors to meet standards.

Adolescents who have no individual risk factors and live in
high-TB-prevalent communities and those with incomplete
or unreliable risk histories or assessment are to be tested,
using the Mantoux test, once between the ages of 11 and
16.
All menstruating adolescents are screened annually with a
hemoglobin and/or hematocrit.
Dipstick urinalysis for leukocytes at age 16 and annually for
sexually active adolescents, males and females. Must screen
for sexual activity.
- - 86 - -
ELEMENTS
7. Immunizations current
AAP Immunizations
AHCA, 10.8.1a, 10.8.9a,
10.8.11a, 20.13 a (10)
AHCA CH CLH, pages 2-17
8. Vital signs
AAP
AHCA CH CLH, pages 2-9
9. Nutritional assessment
AAP
AHCA, 10.8.1.a
AHCA CH CLH, pages 2-2, 2-7
10. Vision screening
AAP
AHCA, 10.8.1.a
AHCA CH CLH, pages 2-2, 2-10,
2-11
11. Hearing screening
AAP
AHCA, 10.8.1.a
AHCA CH CLH, pages 2-2, 2-11,
2-12
12. Physical exam
AAP
AHCA, 10.8.1.a
AHCA CH CLH, pages 2-2, 2-9,
2-11
GUIDELINES
Documentation of immunization status:

An immunization record is present

Immunizations are current in accordance with the
recommendations of the AAP

If immunizations (MMR, TD, varicella, hepatitis B) are not
current, it is noted by the provider and a catch-up plan is
documented; there is evidence the plan is being followed
for new patients; it is documented that immunization
records have been requested and indicate whether they
are reported to be up-to-date for patients with
documentation of a previous request for immunization
records; the immunization record and/or a catch-up plan
is noted in the record within six months or at the next
well-child visit, whichever is sooner.
Pulse, respirations and blood pressure are required at each
well visit.
Assessment incorporates dietary intake, eating habits and
physical growth. The following must be documented for each
well-child visit:

Height

Weight

Dietary intake or an overall nutritional assessment
Vision screening, by physical exam, history and standardized
testing, must be documented. The following minimum
standards are required:

Ages 12, 15 and 18: objective, standardized testing

Ages 11, 13, 14, 16, 17, 19 and 20: subjective assessment
Hearing screening, by physical exam, history and standardized
testing, must be documented. The following minimum
standards are required:

Ages 12, 15 and 18: objective, standardized testing

Ages 11, 13, 14, 16, 17, 19 and 20: subjective assessment
Appropriate evaluation for inclusion in the physical
examination of an asymptomatic adolescent are:

General appearance

Breasts

Skin

Abdomen/GI

Head

Genital/urinary

Gums/dental/oral

Extremities

Eyes/ears/nose/throat

Musculoskeletal

Neck/thyroid

Neurological

Chest/lungs

Lymphatic

Cardiovascular
If noncompliance or refusal for all or portions of the exam,
FL-PM-0024-14
- - 87 - -
ELEMENTS
13. Dental screening
AAP
AHCA, 10.8.1.a
AHCA CH CLH, pages 2-2, 2-10
14. Annual Pap smear
AAP
AHCA CH CLH, pages 2-11, 2-17
USPSTF
15. Chlamydia screening
AHCA CH CLH, pages 2-15
USPSTF
16. Physical and mental health
developmental assessment
AAP
AHCA, 10.8.1.a
AHCA CH CLH, pages 2-2, 2-6,
2-8, 2-9
17. Anticipatory guidance/health
education
AAP
AHCA, 10.8.1.a
AHCA CH CLH, pages 2-18
GUIDELINES
documentation of noncompliance and associated risks are
required.
Dental screening consists of a documented oral exam, and
documentation of PCP recommendation/referral to a dentist
is required.
Annual Pap smears for cervical cancer screening are required
for all sexually active females, regardless of age, and all
females 18 and older. Documentation for females ages 15
through 20 must address sexual activity.
Screening for chlamydia for all sexually active females younger
than 21 is required. Documentation for females ages 15
through 20 must address sexual activity.
Required for each wellness visit. The focus of the assessment
is on areas of special concern for adolescents (e.g., physical
development, potential learning disabilities, social/emotional
development, peer relations, psychological/psychiatric
problems and vocational skills).
Age-appropriate health education and guidance must be
documented for each well-child visit. The following topics are
to be addressed and documented:

Injury prevention

Importance of physical activity

Nutritional counseling

Puberty and general sex education, age appropriate

Pregnancy prevention and STDs, as appropriate for age
and history

School performance and absenteeism

Tobacco/alcohol/drug use and abuse

Violence prevention
Other topics important to adolescents:

The Amerigroup Nurse HelpLine

The Amerigroup website community resources:
- Pregnancy prevention and abstinence programs
- Smoking cessation programs
- Substance abuse programs/resources
- Support groups
FL-PM-0024-14
- - 88 - -
Infant, Young and Middle Childhood
MEDICAL RECORD DOCUMENTATION REVIEW STANDARDS
For Primary Care Providers
ELEMENTS
1. Well-child screening schedule
maintained
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-4, 2-5
Provider Manual
2. Interval history
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-6
3. Developmental history
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-2, 2-6
4. Risk screening
AHCA CH CLH pages 2-6
USPSTF
5. TB risk screening
AAP
AHCA CH CLH pages 2-15, 2-16
USPSTF
6. Lead testing
AAP
AHCA 10.8.1.a
FL-PM-0024-14
GUIDELINES
Periodic comprehensive, preventive health exam visits are
accomplished in accordance with the AAP and AHCA.

Within two to four days following discharge, within 48
hours after delivery or if breastfeeding

By 1 month of age

At ages 2, 4, 6, 9, 12, 15, 18 and 24 months

Annually from ages 2 through 20 years
PCPs are responsible for contacting new members and
scheduling or conducting preventive health for members
within 90 days of assignment to their panel.
An interval history is required at each wellness visit. Changes
in medical, emotional and social status are documented.
A developmental history that provides information regarding
the infant’s/child’s physical, cognitive and emotional
development must be documented.
Screening to identify high-risk individuals, assessing family,
medical and social history, is required. If high-risk indicators
are present, appropriate follow-up or a rationale for no
intervention is documented. See Amerigroup Florida’s High=risk Intervention Guide for a summary of the U.S. Preventive
Services Task Force recommendations.
Screening for TB risk factors is required beginning at 12
months.
Infants/children who have no risk factors and live in low-TBprevalent communities do not need routine Mantoux testing,
but the record must reflect an assessment of risk factors.
Infants/children who have no individual risk factors and live in
high-TB-prevalent communities and those with
incomplete/unreliable risk histories are to be tested, using the
Mantoux test, once between ages 4 and 6 years.
Blood lead levels are required as follows:

Age 12 months

Age 24 months
- - 89 - -
ELEMENTS
AHCA CH CLH, pages 2-2, 2-13,
2-14
USPSTF
7. Hemoglobin or hematocrit
testing
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-2, 2-15
8. Urinalysis testing
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-16
9. Immunizations current
AAP Immunizations
AHCA 10.8.1a, 10.8.9a,
10.8.11a, 20.13.a (10)
AHCA CH CLH pages 2-18, 2-19
10. Vital signs
AAP
AHCA CH CLH pages 2-9
11. Nutritional assessment
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-2, 2-7
FL-PM-0024-14
GUIDELINES

Members who are between the ages of 36 and 72 months
when there is no previously documented lead level

Any time a member is identified as high risk to lead
exposure as indicated by a yes answer to one or more
questions on a lead risk assessment survey
Hemoglobin and/or hematocrit testing are required at 18
months and 24 months of age.
Urinalysis testing at age 5.
To meet standards:

An immunization record is present

Immunizations are current in accordance with AAP
recommendations

If immunizations are not current, it is noted by the
provider and a catch-up plan is addressed; there is
evidence the plan is being followed (Catch-up plans are
evaluated using American Academy of Pediatrics,
Committee on Infectious Diseases catch-up
recommendations)

For new patients, it is documented that immunization
records have been requested

For patients with documentation of a previous request for
immunization records, the immunization record and/or a
catch-up plan is noted in the record within six months or
at the next well-child visit (whichever is sooner)

A history of chickenpox is documented in place of the
varicella vaccine when appropriate
Pulse and respirations are required for infants and children of
all ages. Blood pressure is required at each well-child visit,
beginning at age 3.
Assessment incorporates dietary intake, eating habits and
physical growth. The following must be documented for each
well-child visit:

Height

Weight

Head circumference (age 24 months and younger)

Dietary intake or an overall nutritional assessment are
specifically addressed
- - 90 - -
ELEMENTS
12. Growth chart maintained
AHCA CH CLH pages 2-7
13. WIC screening
AHCA CH CLH pages 2-7
14. Vision screening
AAP
AHCA, 10.8.1.a
AHCA CH CLH pages 2-2, 2-10,
2-11
15. Hearing screening
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-2, 2-11,
2-12
16. Physical exam
AAP
AHCA 10.8.1.a
AHCA CH CLH pages 2-2, 2-9
FL-PM-0024-14
GUIDELINES
A growth chart is plotted with height and weight for infants
and children. Head circumference is documented for infants
and children 24 months and younger.
Since the growth chart is intended to help make comparative
assessments, a separate growth chart for each visit does not
meet the intent; values for exams on various dates are to be
plotted on the same chart.
Documentation of participation in or a needs/eligibility
assessment for the Supplemental Nutrition Program for
Women, Infants and Children (WIC) is present for all children
birth to age 5.
Infants and children up to age 5 identified as at risk or
potentially at risk for poor nutrition must be referred to WIC
for a nutritional and eligibility evaluation. Exception:
documentation that this child is not eligible for WIC and there
is patient/family education regarding nutritional needs.
Vision screening by physical exam, history and standardized
testing must be documented. The following minimum
standards are required:

Infancy through 2 years; 7 and 9 years: subjective
assessment

Ages 3, 4, 5, 6, 8 and 10: objective, standardized testing
If a child is found to be too uncooperative to accomplish
standardized testing, this must be documented with plans to
rescreen.
Hearing screening by physical exam, history and standardized
testing must be documented. The following minimum
standards are required:

Infancy through 2 years; 3, 7 and 9 years: subjective
assessment

Ages 4, 5, 6, 8 and 10: objective, standardized testing
If a child is found to be too uncooperative to accomplish
standardized testing, this must be documented with plans to
rescreen.
Appropriate evaluation for inclusion in the physical
examination of an asymptomatic infant/child are:

General appearance

Cardiovascular

Skin

Abdomen/GI

Head/facial features

Genital/urinary

Gums/dental/oral

Extremities

Eyes/ears/nose/throat

Musculoskeletal

Neck/thyroid

Neurological

Chest/lungs

Lymphatic
- - 91 - -
ELEMENTS
GUIDELINES
Physicals are performed on unclothed infants and
appropriately draped children.
Deferred does not meet documentation standards.
Documentation of noncompliance or refusal for portions of
the exam must be documented with the associated risk of the
noncompliance or referral.
17. Dental screening
Dental screening consists of a visual and tactile examination of
AAP
the intra-oral hard and soft tissues and teeth to check for
AHCA 10.8.1.a
obvious abnormalities. Beginning at age 3, an annual
AHCA CH CLH pages 2-2, 2-10
recommendation or referral to a dentist must accompany the
PCP screening.
18. Physical and mental health
A developmental assessment must be documented at each
developmental assessment
well-child visit. Assessments include specific evaluations of
AAP
gross/fine motor skills, communication/language
AHCA 10.8.1.a
development, visual motor integration, auditory processing
AHCA CH CLH pages 2-2, 2-6, 2-8 skills, attention skills, and cognitive and social/emotional
mental health status.
19. Anticipatory guidance/health
Age-appropriate health education and guidance must be
education
documented for each well-child visit. As a minimum, three of
AAP
the following must be addressed for compliance:
AHCA 10.8.1.a

Injury prevention
AHCA CH CLH pages 2-18

Nutritional counseling
Risk of lead poisoning, ages 6 to 72 months

Sleep positioning counseling, birth through 6 months of
age (required for infants under 6 months of age)

Sun protection

Tobacco, alcohol, drug use/abuse (school-age children)

Violence prevention
Other issues important to infants and children:

The Amerigroup Nurse HelpLine

Awareness of community children’s programs

Importance of staying on schedule with child health
checkups and immunizations

Appropriate expectations for use of antibiotics/risk of
overutilization of antibiotics

Appropriate use of health care providers; when to use
PCP, urgent care and emergency rooms
FL-PM-0024-14
- - 92 - -
High-risk Intervention Guide
HIGH-RISK INTERVENTION GUIDE
RISK
RISK FACTORS
Coronary artery  Smoking
disease

Hypertension

High cholesterol

Family history

Obesity

Diabetes

Men over 50 years

Women, post-menopausal

Women over 50 years

Children/adolescents* whose parents
or grandparents younger than 55
years of age had:
- Diagnosed coronary
atherosclerosis by arteriography,
balloon angioplasty or coronary
artery
- Bypass surgery
- Documented myocardial infarction,
angina pectoris, peripheral
vascular
- Disease, cerebrovascular disease or
sudden cardiac death

Children/adolescents whose parents
have an elevated blood cholesterol
level of 240 mg/dL or higher
Hepatitis

Intravenous (IV)/street drug use

High-risk sexual behavior

Current or past HIV-positive partners

Person/partner exchange sex for
money or drugs

Bisexual

Men who have sex with men

Partners with history of IV drug use

Multiple partners

Partners with multiple partners

Unprotected sex

Person/partners with history of STDs

Health care/lab workers
HIV

High-risk sexual behavior (see
Hepatitis above)

Current or past history of IV/street
drug use
FL-PM-0024-14
- - 93 - -
AGE GROUP
All ages with
multiple risk
factors
INTERVENTION
Lifestyle counseling/
intervention:
 Smoking cessation
 Diet and exercise
 Stress reduction
 Screening for high
cholesterol, 2 years
and older
 Nonfasting total
cholesterol for
children/
adolescents with
parental history of
hyper
cholesterolemia
 Fasting lipid profile
for children/
adolescents with
parental history of
premature
cardiovascular
disease
All ages





All ages
*Birth to 2
months


Counseling
regarding high-risk
behaviors
Hepatitis B vaccine
(if series not
documented)
Hepatitis A vaccine
(consider, if not
previously
vaccinated)
Counseling
regarding high-risk
behaviors
Counseling/
HIGH-RISK INTERVENTION GUIDE
RISK
RISK FACTORS

Blood product transfusion between
1978 and 1985

Infants born to high-risk mothers
whose HIV status is unknown*
Influenza

Residents of chronic care facilities*

Suffer chronic cardiopulmonary
disorders, metabolic diseases,
hemoglobinopathies,
immunosuppression, renal
dysfunction*

Health care workers for patients at
risk*

Persons 65 years of age and older
Neural tube

History of pregnancy with neural tube
defects
defect and planning a pregnancy
Pneumococcal
disease





Young immunocompromised children
(ages 24 to 59 months) at high risk of
pneumococcal infections*
Immunocompetent adolescents;
children and adults with chronic
cardiac or pulmonary disease, diabetes
mellitus, anatomic asplenia**
HIV-positive
Immunocompetent institutionalized
individuals
Adults 65 years of age and older
AGE GROUP
INTERVENTION
recommendation
for HIV testing






*6 months
or older
65 or older
-

Women of
childbearin
g age
*24 to 59
months
**4 years
or older
65 and
older






STDs other than
HIV


High-risk sexual behavior (see
Hepatitis above)
Current or past history of IV/street
drug use
All ages,
sexually
active





FL-PM-0024-14
- - 94 - -
Risk counseling
Influenza vaccine,
annually
Offer treatment
with folic acid prior
to conception
Risk counseling
* Prevnar, two
doses per
administration
guidelines (ages 24
to 59 months)
** Pneumococcal
vaccine × 1 (revaccination after five
years at provider
discretion for those
with severe chronic
disease)
Revaccination after
five years at
provider discretion
for adults 75 years
and older
Counseling
regarding high-risk
behaviors
Counseling/
recommendation
for HIV testing
RPR
Screen for
gonorrhea (females)
Screen for
HIGH-RISK INTERVENTION GUIDE
RISK
RISK FACTORS
Tuberculosis














-
FL-PM-0024-14
AGE GROUP
Contact with persons with confirmed
or suspected TB infection
Contact with persons in jail/prison in
past five years
Clinical or radiographic findings
suggesting TB
Are from have parents from or travel
histories to regions of the world with
high prevalence of TB infection (most
countries in Africa, Asia, Latin America
and Middle East)
Parent recently converted from
negative to positive
HIV-positive
Incarcerated individuals
Frequently exposed to the following:
HIV-positive individuals
Homeless populations
Residents of nursing homes
Institutionalized persons
Migrant farm workers
IV/street drug users
Children and adolescents who have no risk
factors and live in high-TB-prevalent
communities and those with
incomplete/unreliable risk histories or
assessments*
- - 95 - -
12 months and older -
INTERVENTION
chlamydia (females)
 Hepatitis B vaccine
(if series not
documented)
 Hepatitis A vaccine
(consider, if not
previously
vaccinated)
Risk counseling
Mantoux testing:
 I: Immediate testing
using Mantoux test
 A: Annual testing
using Mantoux test
 Every two to three
years: Mantoux test
every two to three
years
 *Children: Mantoux
testing once
between ages 4 to 6
years
 Adolescents, once
between 11 and 16
years
Diabetes
MEDICAL RECORD DOCUMENTATION REVIEW STANDARDS
For Primary Care Physicians
ELEMENTS
1. Baseline medical history
ADA, Standards of Medical Care
in Diabetes, 2005, Table 5
2. Baseline physical exam
ADA, Standards of Medical
Care in Diabetes, 2005, Table 5
GUIDELINES
Elements of the baseline medical history are:

Current symptoms

History of glucose control (results of prior A1C records and
lab studies related to the diagnosis of diabetes)

Results of glucose self-monitoring

Exercise history

Eating patterns, nutritional status, weight history; growth
and development in children and adolescents

Previous treatment programs and diabetic education

All current medications, including over-the-counter

Frequency, severity of acute complications such as
ketoacidosis and hypoglycemia

Symptoms and treatment of chronic eye, kidney, nerve,
foot, GI, GU, heart and vascular complications

Risk factors to include smoking, alcohol use, hypertension,
obesity, dyslipidemia and family history

Lifestyle, cultural, psychological and economic factors that
might affect management of diabetes
A baseline physical examination includes the following
assessments:

Height and weight (and comparison to norms in children
and adolescents)

Sexual maturation (during the peripubertal period)

Blood pressure

Fundoscopic examination

Oral, dental

Thyroid palpation

Cardiac

Abdominal

Evaluation of pulses

Extremities/hand/fingers/feet

Skin

Neurological
A comprehensive baseline physical exam is required:

For diabetics newly assigned to the PCP’s panel (within
three months)

Upon diagnosis for diabetics (newly diagnosed members
already established with the PCP’s practice)
* For diabetics younger than 21 years, comparisons to normal
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ELEMENTS
3. Interim history
ADA, Standards of Medical
Care in Diabetes, 2005
4. Follow-up examination
ADA, Standards of Medical
Care in Diabetes, 2005
5. A1C measurement
ADA , Standards of Medical
Care in Diabetes, 2005, Tables
6 and 9
GUIDELINES
growth, development and sexual maturation can be
documented as plotted growth charts, tanner maturation
staging or in narrative descriptions
An interim history must be obtained at each diabetic visit and
should include the following:

Frequency, causes and severity of hypo- or hyperglycemia

Results of blood glucose self-monitoring

Changes patient made to the therapeutic regime

Problems with adherence

Symptoms suggesting complications of diabetes

Other medical illnesses

Psychosocial issues

Lifestyle changes

Continuation of tobacco or alcohol use
Routine follow-up diabetic examinations are indicated at least
every three months for diabetics who are not meeting
treatment goals and at least every six months for those who
are meeting goals. The following must be addressed:

Blood pressure

Follow-up on abnormalities on previous visits

Visual inspection of the feet

Weight

Sexual maturation (in peripubertal patients)
A1C levels are required every three months in patients who are
not meeting treatment goals and every six months if treatment
goals are being met.
Treatment goals:

20 years and older, A1C < 7 percent

Adolescents 13 to 19 years < 7.5 percent

Children 6 to 12 years <8 percent

Children younger than 6 years 7.5 percent to 8.5 percent
6. Lipid measurement
ADA, Standards of Medical
Care in Diabetes, 2005
Fasting lipid profiles are indicated at least annually for adults
and per guidelines below for children.
Treatment goals are:

20 years and older:
- LDL <100 mg/dl (<2.6 mmol/l)
- Triglycerides <150 (<1.7 mmol/l)
- HDL > 40 (>1.1 mmol/l)

Adolescents:
- Measure once at puberty (>12 years), LDL
- < 100 mg/dl measure in 5 years
- If abnormal LDL, >100 mg/dl, continue annual
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ELEMENTS
GUIDELINES
- monitoring
Children ages 2 years to puberty, monitor per high-risk
guidelines
Annual screening for albuminuria.

7. Microalbumin
ADA, Standards of Medical
Care in Diabetes, 2005
8. Annual foot exam
ADA, Standards of Medical
Care in Diabetes, 2005
9. Dilated eye exam
ADA, Standards of Medical
Care in Diabetes, 2005
10. Documentation of results of
dilated eye exams
Medicaid Contract 2004-2006,
20.13.a (9)
AAAHC, Ch. 6, C, H
11. Influenza vaccination
ADA, Standards of Medical Care
in Diabetes, 2005
U.S. Preventive Services Task
Force, 3rd Edition
FL-PM-0024-14
Screening can be performed by the following methods:

Albumin-to-creatinine ratio in a random, spot urine

24-hour urine collection with creatinine, allowing for the
simultaneous measurement of creatinine clearance

Timed (e.g., four-hour or overnight) urine collection

If reagent tablets or dipsticks for microalbumin are used, all
positive results should be confirmed by more specific
methods

Microalbumin, spot urine
A comprehensive foot exam is required annually for all
individuals with diabetes. Exams are to include assessment of:

Structure and biomechanics

Vascular status (including pulses)

Skin integrity

Neurological status/protective sensation
(Semmes-Weinstein monofilament test and tuning fork)
If a podiatry referral is used, documentation of the exam must
be obtained by the PCP and maintained in the record.
Providing a written referral, with request and instructions for
return, will facilitate the prompt return findings.
A dilated eye exam for retinopathy by an ophthalmologist or
optometrist is required annually.
Results of the dilated eye exam must be present in the record.
Providing a written referral, with request and instructions for
return, will facilitate the prompt return of findings.
The influenza vaccine is indicated annually for patients age 6
months and older who have diabetes.
The CDC recommends a vaccination period from September 1
through December 30 (ideally prior to November 30 for highrisk individuals).
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ELEMENTS
12. Pneumococcal vaccination
ADA, Standards of Medical Care
in Diabetes, 2005
U.S. Preventive Services Task
Force, 3rd Edition
13. Diabetic education and
nutrition counseling
ADA, Standards of Medical
Care in Diabetes, 2005
14. Appropriate referral and
follow-up
ADA, Standards of Medical
Care in Diabetes, 2005
Medicaid Contract 2004-2006,
20.13.a(9)
Amerigroup FL, Medical Record
Documentation Review
Standards, General Medical
Care, standard #11
15. Requested tests/consults
accomplished/filed
AAAHC, Std 4, D5, 7, 8; Std 6H
Medicaid Contract 2004-2006,
20. 13, a (5)
16. Treatment plan
ADA, Standards of Medical
Care in Diabetes, 2005
Medicaid Contract 2004-2006,
20.13.9
FL-PM-0024-14
GUIDELINES
The one-time pneumococcal vaccine is indicated for all
patients with diabetes.
Exception: A one-time revaccination is recommended for
patients older than 64 who were previously immunized when
younger than 65 years and the vaccine was administered over
five years ago.
Appropriate diabetic and nutritional education and counseling,
as defined by the ADA will be addressed at each diabetic visit.
Educational goals are to increase understanding of diabetes
and the patient’s role in self-management and ultimately to
reduce or prevent diabetes-related complications.
Complications or high-risk issues are addressed. Consultations
for specialized services, such as podiatry, endocrinology,
cardiology, neurology, etc., are ordered when the patient’s
condition warrants.
Results of the consults and diagnostic tests are available in the
record in a timely manner.
Visits for continuing care of diabetes (every three to six
months) must have treatment plans that address the following:

Treatment goals

Progress towards attaining treatment goals (e.g., glycemic,
and lipid control, weight management, physical activity,
blood pressure)
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References
MEDICAL RECORD REVIEW DOCUMENTATION STANDARDS
REFERENCES
AAAHC
AAP
AAP Immunizations
ACS
AHCA
AHCA CH CLH
AHCA CLH
Provider Manual
USPSTF
FL-PM-0024-14
Accreditation Association for Ambulatory Health Care,
Accreditation Guidebook for Managed Care Organizations, 2009 Edition
American Academy of Pediatrics, Committee on Practice and Ambulatory
Medicine, Recommendations for Preventive Pediatric Health Care, March
2000
American Academy of Pediatrics, Committee on Infectious Diseases,
Recommended Childhood and Adolescent Immunization Schedule: United
States, 2005
American Cancer Society, Guidelines for Colorectal Cancer Screening for
Individuals at Average Risk, Reviewed 2003
Florida Agency for Health Care Administration, Medicaid Contract
2004–2006
Florida Agency for Health Care Administration, Medicaid Child Health
Check-Up Coverage and Limitations Handbook, October 2003
Florida Agency for Health Care Administration, Medicaid Physician Services
Coverage and Limitations Handbook, January 2007
Amerigroup Florida Provider Manual
U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 3rd
Edition
- - 100 - -
Infection Prevention
In order for our providers to ensure members are treated in a safe and sanitary environment, you must
implement nationally recognized Infection Control guidelines, such as those through the CDC. The
infection prevention program’s purpose is to identify and prevent infections and maintain a sanitary
practice environment.
Your office staff must be educated on:
 A process for identifying and preventing infections through activities such as proper hand hygiene
and safe injection practices
 A process for the management of identified hazards, potential threats, near misses, and other
safety concerns; this includes monitoring of products including medications, reagents and solutions
that carry an expiration date
 Being aware of and a process for the reporting of known adverse incidents to the appropriate state
and federal agencies when required by law to do so
 A process to reduce and avoid medication errors
 Prevention of falls or physical injuries involving patients, staff and all others
You must have a written emergency and disaster preparedness plan to address internal and external
emergencies to ensure member safety and includes an evacuation plan.
You must provide for accessible and available health services, ensuring information about services
when provider practices are not open.
Amerigroup and our providers must comply with applicable state and local building codes and
regulations; applicable state and local fire prevention regulations, such as the NFPA 1010 Life Safety
Code, 2000 edition, published by the National Fire Protection Association, Inc.; and applicable federal
regulations.
Provider practice sites must:
 Contain fire-fighting equipment to control a limited fire, including appropriately maintained and
placed fire extinguishers of the proper type for each potential type of fire
 Have prominently displayed illuminated signs with emergency power capability at all exits,
including exits from each floor or hall
 Have emergency lighting, as appropriate to the facility, to provide adequate illumination for
evacuation of member and staff, in case of an emergency
 Have stairwells protected by fire doors, when applicable
 Provide examination rooms, dressing rooms and reception areas that are constructed and
maintained in a manner ensuring member privacy during interviews, examinations, treatment and
consultation
 Operate in a safe and secure manner
 Have provisions to reasonably accommodate disabled individuals
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Ensure you have the necessary personnel, equipment, supplies and procedures to deliver safe care and
handle medical and other emergencies that may arise. Have periodic instruction of all staff in the
proper use of safety, emergency, and fire-extinguishing equipment and hold periodic drills.
These items will be reviewed during site review for each cycle of credentialing and recredentialing. All
items will be scored using the Practitioner Site Office tool.
Risk Management
Risk Management is defined as the identification, investigation, analysis and evaluation of risks and the
selection of the most advantageous method of correcting, reducing or eliminating identifiable risks.
The Risk Management Program at Amerigroup is intended to protect and conserve the human and
financial assets, public image and reputation of the provider of care and/or the organization from the
consequences of risks associated with members, visitors and employees at the lowest reasonable cost:
 To minimize the incidents of legal claims against the provider of care and/or organization
 To enhance the quality of care provided to members
 To control the cost of losses
 To maintain patient satisfaction with the provider of care and the organization
The scope of the Risk Management Program is organization-wide. Each member of the medical care
team has an equally important role to play in minimizing the occurrence of incidents. All providers of
care, agents and employees of Amerigroup have the affirmative duty to report adverse or untoward
incidents (potential or actual) on an incident report and to send the report to specific personnel for
necessary follow-up.
The activities of the risk manager will contribute to the quality of care and a safer environment for
members, employees, visitors and property, as well as to reduce the cost of risk to the provider of care
and the organization.
These activities are categorized as those directed toward loss prevention (pre-loss) and those for loss
reduction (post-loss).
The primary goal of pre-loss activity is to correct, reduce, modify or eliminate all identifiable risk
situations, which could result in claims and litigation for injury or loss.
This can be accomplished through:
 Providing ongoing education and training programs in risk management and risk prevention
 Participating in safety, utilization review, quality assessment and improvement activities
 Interfacing with the medical staff to ensure communication and cooperation in risk management
 Exchanging information with professional organizations, peers and other resources to improve and
update the program
 Analyzing member grievances that relate to member care and the quality of medical services for
trends and patterns
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The primary goal of post-loss activity is the selection of the most advantageous methods of correcting
identifiable risks and claim control. This can be accomplished through an effective and efficient
incident reporting system.
All employees of Amerigroup will be given education on the Internal Incident Reporting System, which
outlines the incident reporting responsibilities and includes the definition of adverse or untoward
incidents, a copy of the plan inquiry form, appropriate routing and the required time frame for
reporting incidents to the risk manager.
Provider input and participation in the QM process further emphasizes the identification of potential
risks in the clinical aspects of member care.
Internal Incident Reporting System
The Internal Incident Reporting System establishes the policy and procedure for reporting adverse or
untoward incidents that occur.
Definitions
Adverse or untoward incident — an event over which health care personnel could exercise control
and:
 Is more probably associated in whole or in part with medical intervention rather than the condition
for which such intervention occurred
 Is not consistent with or expected to be a consequence of such medical interventions
 Occurs as a result of medical intervention to which the member has not given his or her informed
consent
 Occurs as a result of any other action or lack thereof on the part of the facility or personnel of the
facility
 Results in a surgical procedure being performed on the wrong member
 Results in a surgical procedure unrelated to the member’s diagnosis or medical needs being
performed on any member
 Causes injury to a member as defined below
Injury — any of the following outcomes when caused by an adverse incident:
 Death
 Fetal death
 Brain damage
 Spinal damage
 Surgical procedure performed on the wrong site
 Surgical procedure performed on the wrong patient
 Wrong surgical procedure
 Surgical procedure unrelated to the patient’s diagnosis
 Surgical procedure to remove foreign objects remaining from a surgical procedure
These issues are applicable with all Amerigroup members:
 Abuse/neglect
 Altercations
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








Elopement
Escape
Exploitation
Homicide
Injury or illness
Medication errors
Sexual battery
Suicide
Suicide attempt
Reporting Responsibilities
 All incidents involving members must be reported to the risk manager or risk manager designee
within three calendar days. If the incident has resulted in serious or potentially serious member
harm (Code 15), the risk manager must be contacted immediately if during the day, and the
medical director must be contacted immediately if during the night.
 The organization must report Code 15 incidents to the Agency for Health Care Administration
(AHCA) within three calendar days after its occurrence. A more detailed follow-up report must be
submitted to AHCA within 10 days after the first report. AHCA may require an additional final
report.
 All participating and direct service providers are required to report adverse incidents to the
Managed Care Plans within twenty-four (24) hours of the incident. The Managed Care Plan must
ensure that all participating and direct service providers are required to report adverse incidents to
the Agency immediately but not more than twenty-four (24) hours of the incident. Reporting will
include information including the enrollee’s identity, description of the incident and outcomes
including current status of the enrollee.
 Amerigroup shall report suspected adult abuse, neglect and exploitation of enrollees immediately,
in accordance with Chapter 415, F.S. Suspected cases of abuse, neglect and/or exploitation must be
reported to the state’s Adult Protective Services Unit. The Florida Adult Protective Services has the
responsibility for investigating allegations of abuse, neglect and exploitation of elders and
individuals with disabilities.
 Additionally, Amerigroup reports any related behavioral health clinical incidents to AHCA monthly.
Procedural Responsibilities
 The provider staff member involved in observing or first discovering the unusual incident or an
Amerigroup staff member who becomes aware of an incident is responsible for initiating the
incident report before the end of the working day. Reports will be fully completed on the incident
report form and will provide a clear, concise, objective description of the incident. The director of
the department involved in observing the risk situation will assist in the completion of the form, if
necessary.
 The director of the department involved will forward all incident reports to the risk manager or risk
manager designee within three calendar days. Upon being logged and date-stamped by the risk
manager, the QM department will solicit information from other departments and/or providers. All
incident reports resulting in serious or potentially serious member harm will be forwarded to the
risk manager or risk manager designee immediately for consideration of Code 15 reporting.
 The National Customer Care department associate is responsible for initiating incident reports for
member grievances that relate to an adverse or untoward incident.
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







The QM Committee will review all pertinent safety-related reports.
The QM Committee, MAC and/or Peer Review Committee will review pertinent member-related
reports.
Documentation related to the suspected abuse, neglect or exploitation, including the reporting of
such, must be kept in a file, separate from the enrollee’s case file, that is designated as
confidential. Such file shall be made available to the Agency upon request
The only copy of a member incident report will be kept in the office of the risk manager, and
reports will not be photocopies or carbon copies. Employees, providers and agents are prohibited
from placing copies of an incident report in the medical record. Employees, providers and agents
are prohibited from making a notation in the medical record referencing the filing of an incident
report.
The risk manager will communicate with department directors and managers to provide follow-up,
as appropriate. If corrective action is needed on the part of an Amerigroup associate, the Human
Resources department will execute.
The risk manager will follow up on all incidents pertinent to quality to determine causes and
possible preventive interventions.
The risk manager will keep statistical data of incidents for analysis purposes.
Original incident reports will be maintained in the office of the risk manager for a minimum of six
months.
Incident Report Review and Analysis
 The risk manager will review all incident reports and analyze them for trends and patterns. This
includes the frequency, cause and severity of incidents by location, practitioner and type of
incident.
 The risk manager will have free access to all health maintenance organization or provider medical
records.
 The incident reports will be utilized to develop categories of incidents that identify problems.
 Once problems become evident, the risk manager will make recommendations for corrective
actions, such as procedure revisions.
 Should definitive injuries occur, cases will be categorized using the ICD-9-CM coding classification.
An incident report is an official record of incident and is privileged and confidential in all regards. No
copies will be made of any incident report for any reason, other than those situations authorized by
applicable law.
Credentialing
Amerigroup credentialing policies and procedures incorporate the current National Committee for
Quality Assurance (NCQA) Standards and Guidelines for the Accreditation of Managed Care
Organizations as well as the Florida Department of Health (FDOH) requirements for the credentialing
and recredentialing of licensed independent providers and organizational providers with whom we
contract.
Amerigroup will accept the provider’s copy of the Council for Affordable Quality Healthcare (CAQH)
applications in lieu of an Amerigroup application form.
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Each provider agrees to submit for verification all requested information necessary to credential or
recredential physicians providing services in accordance with the standards established by Amerigroup.
Each provider will cooperate with Amerigroup as necessary to conduct credentialing and
recredentialing pursuant to our policies, procedures and rules.
Credentialing Requirements
Each provider, applicable ancillary/facility and hospital will remain in full compliance with the
Amerigroup credentialing criteria as set forth in our credentialing policies and procedures and all
applicable laws and regulations. Each provider, applicable ancillary/facility and hospital will complete
the Amerigroup application form upon request. Each provider will comply with other such
credentialing criteria as may be established by Amerigroup. We are authorized to take whatever steps
necessary to ensure each provider is recognized by the state Medicaid program, including its choice
counseling/enrollment broker contractor(s) as a participating provider of Amerigroup, and the
provider’s submission of encounter data is accepted by the Florida Medicaid Management Information
Systems and/or the state’s encounter data warehouse. Each provider must supply us with his or her
Medicaid information number or complete the managed care treating provider registration form prior
to participation.
Each provider must have a unique Florida Medicaid provider number, Medicaid provider registration
number or documentation of submission of the Medicaid provider registration form.
Amerigroup requires each provider to have a National Provider Identifier (NPI) in accordance with s.
1173(b) of the Social Security Act, as enacted by s. 4707(a) of the Balanced Budget Act of 1997.
Credentialing Procedures
We are committed to operating an effective, high-quality credentialing program. We credential the
following provider types: medical doctors, doctors of osteopathy, doctors of dental surgery, doctors of
dental medicine, doctors of podiatric medicine, doctors of chiropractic, physician assistants,
optometrists, dentists, nurse practitioners, certified nurse midwives, licensed professional
counselors/social workers, psychologists, physical/occupational therapists, speech/language
therapists, and other applicable or appropriate mid-level providers as well as hospitals and allied
services (ancillary) providers.
During recredentialing, each provider must show evidence of satisfying these policy requirements and
must have satisfactory results relative to Amerigroup measures of quality of health care and service.
We will establish a Credentialing Committee and a MAC for the formal determination of
recommendations regarding credentialing decisions. The Credentialing Committee will make decisions
regarding participation of initial applicants and their continued participation at the time of
recredentialing. The oversight rests with the MAC.
The Amerigroup credentialing policy is revised periodically based on input from several sources,
including but not limited to, the Credentialing Committees, the health plan medical director, the
Amerigroup chief medical officer, and state and federal requirements. The policy will be reviewed and
approved as needed, but at a minimum annually.
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The provider application contains the provider’s actual signature that serves as an attestation of the
credentials summarized on and included with the application. The provider’s signature also serves as a
release of information to verify credentials externally. We are responsible for externally verifying
specific items attested to on the application. Any discrepancies between information included with the
application and information obtained by Amerigroup during the external verification process will be
investigated and documented and may be grounds for refusal of acceptance into the network or
termination of an existing provider relationship. The signed agreement documents compliance with
Amerigroup managed care policies and procedures.
All providers have the right to inquire about the status of their applications. They may do so by the
following methods: (1) telephone, (2) facsimile, (3) contact through their Provider Relations
representative or (4) in writing.
As an applicant for participation with Amerigroup, each provider has the right to review information
obtained from primary verification sources during the credentialing process. Upon notification from
Amerigroup, the provider has the right to explain information obtained that may vary substantially
from that provided and to provide corrections to any erroneous information submitted by another
party. The provider must submit a written explanation or appear before the Credentialing Committee if
deemed necessary.
Currently, the following verifications are completed as applicable prior to final submission of a
practitioner file to the health plan medical director or Credentialing Committee. To the extent allowed
under applicable law or state agency requirements, per NCQA Standards and Guidelines, the medical
director has authority to approve clean files without input from the Credentialing Committee. All files
not designated as a clean file will be presented to the Credentialing Committee for review and decision
regarding participation.
In addition to the submission of an application and the execution of a participating provider
agreement, the following must be reviewed and approved by the Credentialing Committee or the
medical director:
1. Verification of enrollment — If group enrollment, verification that provider is linked appropriately
to the group and that the provider is enrolled at the appropriate service locations.
2. Board certification — Verification by referencing the American Medical Association Provider
Profile, American Osteopathic Association, the American Board of Medical Specialties, American
Board of Podiatric Surgery, and/or American Board of Podiatric Orthopedics and Primary Podiatric
Medicine.
3. Verification of education and training — Verification by referencing board certification or the
appropriate state-licensing agency.
4. Verification of work history — The practitioner must submit a curriculum vitae documenting work
history for the past five years. Any gaps in work history greater than six months must be explained
in written format and brought to the attention of the medical director and Credentialing
Committee as applicable.
5. Hospital affiliations and privileges — To the extent allowed under applicable law or state agency
requirements, verification of clinical privileges in good standing at an Amerigroup network hospital
may be accomplished by the use of an attestation signed by the provider. If attestation is not
acceptable, hospital admitting privileges in good standing are verified for the practitioner. This
information is obtained in the form of a written letter from the hospital, roster format (multiple
FL-PM-0024-14
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practitioners), Internet access or by telephone contact. The date and name of the person spoken to
at the hospital are documented.
6. State licensure or certification — Verification of state license information to ensure that the
practitioner maintains a current legal license or certification to practice in the state. This
information can be verified by referencing data provided to Amerigroup by the state via roster,
telephone or the Internet.
7. DEA number — Verification of the Drug Enforcement Administration (DEA) number to ensure that
the practitioner is currently eligible to prescribe controlled substances. This information is verified
by obtaining a copy of the DEA certificate or by referencing the National Technical Information
Service (NTIS) data. If the practitioner is not required to possess a DEA certificate but does hold a
state-controlled substance certificate, the Controlled Dangerous Substance (CDS) certificate is
verified to ensure the practitioner is currently eligible to prescribe controlled substances. This
information is verified by obtaining a copy of the CDS certificate or by referencing CDS online or
Internet data, if applicable.
8. Professional liability coverage — To the extent allowed under applicable law or state agency
requirements, verification of malpractice coverage may be accomplished by the use of an
attestation signed by the provider indicating the name of the carrier, policy number, coverage
limits, and the effective and expiration dates of such malpractice coverage. If attestation is not
acceptable, the practitioner’s malpractice insurance information is verified by obtaining a copy of
the professional liability insurance face sheet from the practitioner or from the malpractice
insurance carrier. Practitioners are required to maintain professional liability insurance in specified
amounts.
9. Professional liability claims history — Verification of an applicant’s history of professional liability
claims, if any, reviewed by the Health Plan Credentialing Committee to determine whether
acceptable risk exposure exists. The review is based on information provided and attested to by the
applicant and information available from the National Practitioner’s Data Bank (NPDB). The
Credentialing Committee’s policy is designed to give careful consideration to the medical facts of
the specific cases, total number and frequency of claims in the past five years, and the amounts of
settlements and/or judgments.
10. CMS sanctions — Verification that the practitioner’s record is clear of any sanctions by CMS. This
information is verified by accessing the NPDB.
11. Disclosures – attestation and release of information — The Amerigroup provider application will
require responses to the following:
 Reasons for the inability to perform the essential functions of the position with or without
accommodation
 Any history or current problems with chemical dependency or alcohol or substance abuse
 History of license revocations, suspension, voluntary relinquishment, probationary status, or
other licensure conditions or limitations
 History of conviction of any criminal offense other than minor traffic violations
 History of loss or limitation of privileges or disciplinary activity, including denial, suspension,
limitation, termination or nonrenewal of professional privileges
 History of complaints or adverse action reports filed with a local, state or national professional
society or licensing board
 History of refusal or cancellation of professional liability insurance
 History of suspension or revocation of a DEA or CDS certificate
 History of any CMS sanctions
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

Attestation by the applicant of the correctness and completeness of the application
Written explanation of any issue identified; these explanations are presented with the
provider’s application to the Credentialing Committee
12. NPDB — The NPDB is queried against applicants and the Amerigroup contracted providers. The
NPDB will provide a report for every practitioner queried. These reports are shared with the
medical director and the Credentialing Committee for review and action as appropriate. The
Federation of State Medical Boards for doctors of medicine, doctors of osteopathy and physician
assistants is queried to verify any restrictions/sanctions made against the practitioner’s license. The
appropriate state-licensing agency is queried for all other providers. All sanctions are investigated
and documented, including the health plan’s decision to accept or deny the applicant’s
participation in the network.
13. Office location review — At the time of initial credentialing, an Amerigroup representative will
complete a site visit for each office location of all providers to determine whether the provider’s
office can accommodate the members and meets all requirements.
14. Recredentialing — At the time of recredentialing (every three years), information for PCPs from
quality improvement activities and member complaints is presented for Credentialing Committee
review.
The provider will be notified by telephone or in writing if any information obtained in support of the
assessment or reassessment process varies substantially from the information submitted by the
provider. Providers have the right to review the information submitted in support of the credentialing
and recredentialing process and to correct any errors in the documentation. This will be accomplished
by submission of a written explanation or by appearance before the Credentialing Committee if so
requested.
The decision to approve or deny initial participation will be communicated in writing within 60 days of
the Credentialing Committee’s decision. To the extent allowed under applicable law or state agency
requirements, per NCQA Standards and Guidelines, the medical director may render a decision
regarding the approval of clean files without benefit of input from the Credentialing Committee. In the
event the provider’s continued participation is denied, the provider will be notified by certified mail. If
continued participation is denied, the provider will be allowed 30 days to appeal the decision.
Credentialing Organizational Providers
The provider application contains the provider’s actual signature that serves as an attestation that the
health care facility agrees to the assessment requirements. Providers requiring assessments are as
follows: hospitals, home health agencies, skilled nursing facilities, nursing homes, ambulatory surgical
centers and behavioral health facilities providing mental health or substance abuse services in an
inpatient, residential or ambulatory setting. The provider’s signature also serves as a release of
information to verify credentials externally.
Currently, the following steps are completed in addition to the application and network provider
agreement before approval for participation of a hospital or organizational provider.
State licensure is verified by obtaining a current copy of the state license from the organization or by
contacting the state licensing agency. Primary source verification is not required. Any restrictions to a
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license are investigated and documented, including the decision to accept or deny the organization’s
participation in the network.
We contract with facilities that meet the requirements of an unbiased and recognized authority.
Hospitals (e.g., acute, transitional or rehabilitation) should be accredited by the Joint Commission on
Accreditation of Health Care Organizations (JCAHO), Health Care Facilities Accreditation Program
(HFAP) or the American Osteopathic Association (AOA). The Commission on Accreditation of
Rehabilitation Facilities (CARF) may accredit rehabilitation facilities. Home health agencies should be
accredited by JCAHO or the Community Health Accreditation Program (CHAP). Nursing homes should
be accredited by JCAHO. JCAHO or the Accreditation Association for Ambulatory Health Care (AAAHC)
should accredit ambulatory surgical centers.
If facilities, ancillaries or hospitals are not accredited, Amerigroup will accept a copy of a recent state
or CMS review in lieu of performing an on-site review. If accreditation or copy of a recent review is
unavailable, an on-site review will be performed.
 A copy of the malpractice insurance face sheet is required. Organizations are required to maintain
malpractice insurance in the amounts specified in the provider contract and according to
Amerigroup policy.
 We will track a facility’s/ancillary’s reassessment date and reassess every 36 months as applicable.
Requirement for recredentialing of organizational providers are the same for reassessment as they
are for the initial assessment.
The organization will be notified, either by telephone or in writing, if any information obtained in
support of the assessment or reassessment process varies substantially from the information
submitted by the organization.
Organizations have the right to review the information submitted in support of the assessment process
and to correct any errors in the documentation. This will be accomplished by submission of a written
explanation or by appearance before the Credentialing Committee, if so requested.
The decision to terminate an organization’s participation will be communicated in writing via certified
mail.
Delegated Credentialing
We will ensure the quality of our credentialing program through direct verification and through
delegation of credentialing functions to qualified provider organizations. Where a provider group is
believed to have a strong credentialing program, we may evaluate a delegation of credentialing and
recredentialing. The provider group must have a minimum of 150 participating providers.
The Credentialing department will review the written credentialing policy of the group for adequacy.
Steps, if any, are identified where the group’s credentialing policy does not meet the Amerigroup
standards. We will perform or arrange for the group to perform the Amerigroup credentialing steps
not addressed by the group.
We will perform a predelegation audit of the group’s credentialing practices. A passing score is
considered to be an overall average of 90 percent compliance. The group is expected to submit an
acceptable corrective action plan within 30 days of receipt of the audit results.
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If there are serious deficiencies, we will deny the delegation or will restrict the level of delegation.
We may, at our discretion, waive the need for the predelegation on-site audit if the delegated entity’s
credentialing program is NCQA-certified to include all credentialing and recredentialing elements.
Amerigroup is responsible for oversight of any delegated credentialing arrangement and schedules
appropriate reviews. The reviews are held at least annually.
Peer Review
The peer review process provides a systematic approach for monitoring the quality and
appropriateness of care.
Peer review responsibilities are:
 To participate in the implementation of the established peer review system
 To review and make recommendations regarding individual provider peer review cases
 To work in accordance with the executive medical director
Should investigation of a member grievance result in concern regarding a physician’s compliance with
community standards of care or service, all elements of peer review will be followed.
Dissatisfaction severity codes and levels of severity are applied to quality issues. The medical director
assigns a level of severity to the grievance. Peer review includes investigation of physician actions by or
at the discretion of the medical director. The medical director takes action based on the quality issue
and the level of severity, invites the cooperation of the physician, and consults and informs the MAC
and Peer Review Committee. The medical director informs the physician of the committee’s decision,
recommendations, follow-up actions and/or disciplinary actions to be taken. Outcomes are reported to
the appropriate internal and external entities, which include the QM Committee.
The peer review process is a major component of the MAC monthly agenda. The peer review policy is
available upon request.
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MEMBER APPEAL AND GRIEVANCE PROCEDURES
Amerigroup has a formal appeal and grievance process for the handling of disputes pertaining to
administrative issues and nonpayment-related matters. For payment disputes, see the Provider
Payment Disputes section.
The appeal process is the procedure for addressing member appeals, which are requests for review of
an action. Actions are defined as the following:
 The denial or limited authorization of a requested service, including the type or level of service
pursuant to 42 CFR 438 400(b)
 The reduction, suspension or termination of a previously authorized service
 The denial, in whole or part, of a payment for a service
 The failure to provide services in a timely manner as defined by the state
 The failure of the plan to act within the time frames provided in Sec. 438.408(b)
Members have the right to tell Amerigroup if they are not happy with their care or the coverage of
their health care needs. These are called “Grievances and Appeals.”
A grievance is when a member is unhappy about something besides his or her health benefits. A
grievance could be about a doctor’s behavior or about information the member should have received
but did not.
An appeal is when a member feels he or she should be getting a service covered and is not, or when a
service has been discontinued or stopped.
Complaints and Grievances
Amerigroup has a process to solve complaints and grievances. If a member has a concern that is easy
to solve and can be resolved within 24 hours, Member Services can help.
If the concern cannot be handled within 24 hours and needs to be looked at by our grievance
coordinator, the concern is noted and turned over to the grievance coordinator.
A complaint or grievance must be given orally or in writing within one year of the occurrence.
To file a complaint or grievance, the member can:
1. Call Member Services at 1-800-600-4441. If you are deaf or hard of hearing, call the toll-free AT&T
Relay Service at 1-800-855-2880.
2. Write us a letter regarding the concern and mail it to:
Grievance Coordinator
Amerigroup Community Care
4200 West Cypress St., Suite 900
Tampa, FL 33607-4173
Members can have someone else help them with the grievance process. This person can be:
 A family member
 A friend
 A doctor
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
A lawyer
The member must give written permission in order for someone else to file a grievance or an appeal on
his or her behalf.
If a member needs help filing the complaint, Amerigroup can help. Call Member Services at 1-800-6004441. If you are deaf or hard of hearing, call the toll-free AT&T Relay Service at 1-800-855-2880.
If the member or member’s representative would like to speak with the grievance coordinator to give
more information, tell Member Services when the complaint is filed or put it in a letter.
Once Amerigroup gets the grievance (oral or written), we send the member a letter within five working
days telling them the date we received the grievance.
What happens next?
1. The grievance coordinator reviews the concern.
2. If more information is needed or you have asked to talk to the coordinator, the coordinator will call
the member or the designated representative.
3. If you have more information to give us, you can bring it to us in person or mail it to:
Grievance Coordinator
Amerigroup Community Care
4200 West Cypress St., Suite 1000
Tampa, FL 33607-4173
4. Medical concerns are looked at by medical staff.
5. Amerigroup will tell the member the decision of the grievance within 30 calendar days from the
date we received the grievance.
What can a member do if he or she is unhappy with the decision?
Members have the right to file a state fair hearing. The member must do so no later than 90 days from
the date he or she received notice that coverage of a service has been denied, stopped, reduced or
delayed.
The Office of Appeal Hearings is not part of Amerigroup. They look at grievances of Medicaid members
who live in Florida. If you contact the Office of Appeal Hearings, we will give them information about
your case, including the information you have given us.
To ask for a state fair hearing contact:
Department of Children and Families
Office of Appeal Hearings
Building 5, Room 255
1317 Winewood Blvd.
Tallahassee, FL 32399-0700
Phone: 850-488-1429
Fax: 850-487-0662
Email: [email protected]
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Note: Members cannot ask for a Medicaid fair hearing if they have MediKids.
Members have the right to ask to receive benefits while the hearing is pending by calling Member
Services toll free at 1-800-600-4441. If you are deaf or hard of hearing, please call the AT&T Relay
Service toll free at 1-800-855-2880.
Medical Appeals
There may be times when Amerigroup says it will not pay, in whole or in part, for care that a member’s
doctor recommended. If we do this, a member or someone on behalf of a member (with the member’s
written consent) can appeal the decision. A medical appeal is when Amerigroup is asked to look again
at the care being asked for that we said we will not pay for. Members must file for an appeal within 30
days from the date on the letter that says Amerigroup has denied, limited, reduced, suspended or
terminated services. Amerigroup will not hold it against the member or the doctor for filling an appeal.
The member can have someone else help them with the appeal process. This person can be a family
member, a friend, your doctor or a lawyer. Write this person’s name on the appeal form and fill out a
request to designate a personal representative form.
Members can ask us to send you more information to help them understand why we would not pay for
the service you requested.
I want to ask for an appeal. How do I do it?
An appeal may be filed verbally or in writing within 30 calendar days of when the member gets the
notice of action. Except when expedited resolution is required, an oral notice must be followed by a
written notice within 10 calendar days of the oral notice. The date of the oral notice will be the date
Amerigroup received the notice.
There are two ways to file an appeal:
1. Write us and ask to appeal
2. Call Member Services at 1-800-600-4441 and ask to appeal. If you are deaf or hard of hearing,
please call the AT&T Relay Service toll free at 1-800-855-2880.
What else do I need to know?
If a member or the member’s representative calls Amerigroup, we will send the member an appeal
form. If the member wants someone else to help you with the appeal process, let us know, and we will
send the member a form for that. Fill out the form. Mail it back to us. The member must mail it back to
us within 10 days of the oral notification. We need the appeal in writing to continue. We can help the
member fill out the form when we talk on the phone.
When Amerigroup receives the appeal letter or form, we will send the member a letter within five
business days notifying them of the receipt of the appeal request.
The member or the representative may talk to the doctor who looks at the appeal to give more
information. We can arrange for the member to talk to this person. Or you can mail it to us.
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Members may ask for a free copy of the guidelines, records or other information used to make the
denial and/or appeal decision.
We will notify the member of the decision within 30 calendar days of getting the appeal request.
If we reduce coverage for a service a member is receiving and the member wants to continue to get
the service during the appeal, the member can call Amerigroup to ask for continuation of benefits. The
member must call within 10 days of the date of the letter that tells him or her that Amerigroup will not
pay for the service.
If you or the member has more information to give us, you can bring it in person or mail it to the
address below. Also, the member can look at your medical records and information on this decision
before and during the appeal process.
The time frame for an appeal may be extended up to 14 calendar days if:
 The member asks for an extension
 Amerigroup finds additional information is needed, and the delay is in the member’s interest
If the time frame of the appeal is extended other than at the member’s request, Amerigroup will notify
the member in writing within five business days of when the decision is made.
If a member has a special need, Amerigroup will give additional help to file the appeal. Please call
Member Services at 1-800-600-4441, Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time.
If you are deaf or hard of hearing, please call the AT&T Relay Service at 1-800-855-2880.
Where do I mail my letter?
Mail all medical information and medical necessity appeals to:
Medical Appeals
Amerigroup Community Care
P.O. Box 62429
Virginia Beach, VA 23466-2429
What can I do if Amerigroup still will not pay?
The member or representative on the member’s behalf with the member’s written consent has a right
to ask for a state fair hearing. Members do not need to file an appeal before they request a fair
hearing. If the member would like to request a fair hearing, he or she must do so no later than 90 days
from the date of the letter.
The Office of Appeal Hearings is not part of Amerigroup. They look at appeals of Medicaid members
who live in Florida.
If you contact the Office of Appeal Hearings, we will give them information about your case, including
the information you have given us.
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Members have the right to ask to receive benefits while the hearing is pending by calling Member
Services toll free at 1-800-600-4441. If you are deaf or hard of hearing, please call the AT&T Relay
Service toll free at 1-800-855-2880.
Note: Members cannot ask for a Medicaid fair hearing if they have MediKids.
How do I contact the state for a state fair hearing?
You can contact the Office of Appeal Hearings at any time during the Amerigroup appeals process at:
DCF/Office of Appeal Hearings, Building 5, Room 255,
1317 Winewood Boulevard
Tallahassee, FL 32399-0700
What can I do if I think I need an urgent or expedited appeal?
Members can ask for an urgent or expedited appeal if they or their physician thinks the time frame for
a standard appeal process could seriously jeopardize the member’s life or health or ability to attain,
maintain or regain maximum function.
Members can also ask for an expedited appeal by calling Member Services toll free at 1-800-600-4441,
Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. If you are deaf or hard of hearing,
please call the AT&T Relay Service toll free at 1-800-855-2880.
We must respond to the expedited request within three business days (72 hours) after we receive the
appeal request, whether the appeal was made verbally or in writing.
If the request for an expedited appeal is denied, the appeal will be transferred to the time frame for
standard resolution, and the member will be notified within three business days (72 hours).
If you have any questions or need help, please call Member Services toll free at 1-800-600-4441,
Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern time. If you are deaf or hard of hearing,
please call the AT&T Relay Service toll free at 1-800-855-2880.
How do I ask for an external appeal review?
After receiving a final determination from Amerigroup, you can call or write the Beneficiary Assistance
Program (BAP):
Agency for Health Care Administration
Beneficiary Assistance Program
2727 Mahan Drive, Building 1, M.S. 26
Tallahassee, FL 32308
1-888-419-3456 or 1-850-412-4502
Before filing with the BAP, you must finish the Amerigroup appeals process.
You must ask for the appeal to the BAP within one year after receipt of the final decision letter from
Amerigroup.
The BAP will not handle an appeal that has already been to a Medicaid fair hearing.
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The BAP will finish its review and make a decision.
CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
Electronic Submission
Amerigroup encourages the submission of claims electronically through Electronic Data Interchange
(EDI). Providers must submit claims within 180 days from the date of discharge for inpatient services or
from the date of service for outpatient services. Electronic claims submission is available through:
 Emdeon (formerly WebMD) — Claim payer ID 27514
 Capario (formerly MedAvant) — Claim payer ID 28804
 Availity (formerly THIN) — Claim payer ID 26375
The advantages of electronic claims submission are as follows:
 Facilitates timely claims adjudication
 Acknowledges receipt and rejection notification of claims electronically
 Improves claims tracking
 Improves claims status reporting
 Reduces adjudication turnaround
 Eliminates paper
 Improves cost-effectiveness
 Allows for automatic adjudication of claims
The guide for EDI claims submission is located at providers.amerigroup.com/FL. The EDI claim
submission guide includes additional information related to the EDI claim process.
To initiate the electronic claims submission process or obtain additional information, please contact
the Amerigroup EDI Hotline at 1-800-590-5745.
Paper Claims Submission
Providers also have the option of submitting paper claims. Amerigroup uses Optical Character Reading
(OCR) technology as part of its front-end claims processing procedures. The benefits include the
following:
 Faster turnaround times and adjudication
 Claims status availability within five days of receipt
 Immediate image retrieval by Amerigroup staff for claims information allowing more timely and
accurate response to provider inquiries
In order to use OCR technology, claims must be submitted on original red claim forms (not black-andwhite or photocopied forms) and laser printed or typed (not handwritten) in a large, dark font.
Providers must submit a properly completed CMS-1450 or CMS-1500 (08-05) within 180 days from the
date of discharge for inpatient services or from the date of service for outpatient services, except in
cases of coordination of benefits/subrogation or in cases where a member has retroactive eligibility.
For cases of coordination of benefits/subrogation, the time frames for filing a claim will begin on the
date that the third party documents resolution of the claim.
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Paper claims must be submitted within 180 days of the date of service and submitted to the following
address:
Florida Claims
Amerigroup Community Care
P.O. Box 61010
Virginia Beach, VA 23466-1010
Encounter Data
Amerigroup has established and maintains a system to collect member encounter data. Due to
reporting needs and requirements, network providers who are reimbursed by capitation must send
encounter data to Amerigroup for each member encounter. Encounter data can be submitted through
EDI submission methods or on a CMS-1500 (08-05) claim form unless other arrangements are
approved by Amerigroup. Data will be submitted in a timely manner, but no later than 180 days from
the date of service.
The encounter data will include the following:
 Member ID number
 Member name (first and last name)
 Member date of birth
 Provider name according to contract
 Amerigroup provider ID
 Coordination of benefit information
 Date of encounter
 Diagnosis code
 Types of services provided (using current procedure codes and modifiers if applicable)
 Provider tax ID number and state Medicaid ID number
Encounter data should be submitted to the following address:
Amerigroup Community Care
P.O. Box 61010
Virginia Beach, VA 23466-1010
Through claims and encounter data submissions, HEDIS® information is collected. This includes, but is
not limited to, the following:
 Preventive services (e.g., childhood immunization, mammography, Pap smears)
 Prenatal care (e.g., LBW, general first trimester care)
 Acute and chronic illness (e.g., ambulatory follow-up and hospitalization for major disorders)
Compliance is monitored by the Amerigroup utilization and quality improvement staff, coordinated
with the medical director and reported to the Quality Management Committee on a quarterly basis.
The Primary Care Provider (PCP) is monitored for compliance with reporting of utilization. Lack of
compliance will result in training and follow-up audits and could result in termination from the
network.
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Claims Adjudication
Amerigroup is dedicated to providing timely adjudication of provider claims for services rendered to
members. All network and non-network provider claims that are submitted for adjudication are
processed according to generally accepted claims coding and payment guidelines. These guidelines
comply with industry standards as defined by the CPT-4 and ICD-9 Manuals. Institutional claims should
be submitted using EDI submission methods or a UB-04 CMS-1450 or successor forms; provider
services should be submitted using the CMS-1500.
Providers must use HIPAA-compliant billing codes when billing Amerigroup. This applies to both
electronic and paper claims. When billing codes are updated, the provider is required to use
appropriate replacement codes for submitted claims. Amerigroup will not pay any claims submitted
using noncompliant billing codes.
Amerigroup reserves the right to use code-editing software to determine which services are
considered part of, incidental to or inclusive of the primary procedure.
For claims payment to be considered, providers must adhere to the following time limits:
 Submit claims within 180 days from the date the service is rendered; for inpatient claims filed by a
hospital, submit claims within 120 days from the date of discharge
 In the case of other insurance, submit claims within 180 days of receiving a response from the
third-party payer
 Claims for members whose eligibility has not been added to the state’s eligibility system must be
received within 180 days from the date the eligibility is added and Amerigroup is notified of the
eligibility/enrollment. Claims submitted after the 180-day filing deadline will be denied
After filing a claim with Amerigroup, review the Explanation of Payment (EOP). If the claim does not
appear on an EOP within 30 business days as adjudicated or you have no other written indication that
the claim has been received, check the status of your claim using the Amerigroup provider website at
providers.amerigroup.com/FL or the telephonic Provider Inquiry Line at 1-800-454-3730. If the claim is
not on file with Amerigroup, resubmit your claim within 180 days from the date of service. If filing
electronically, check the confirmation reports for acceptance of the claim that you receive from your
EDI or practice management vendor.
Clean Claims Payment
A clean claim is a request for payment for a service rendered by a provider that:
 Is submitted by the provider in a timely manner
 Is accurate
 Is submitted on a HIPAA-compliant standard claim form, including a CMS-1500 or CMS-1450, or
successor forms thereto, or the electronic equivalent of such claim form
 Requires no further information, adjustment or alteration by the provider or by a third party in
order to be processed and paid by Amerigroup
Clean claims are adjudicated within 30 business days of receipt. If Amerigroup does not adjudicate the
clean claim within the time frames specified above, we will pay all applicable interest as required by
law.
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We produce and mail an EOP on a biweekly basis, which delineates the status of each claim that has
been adjudicated during the previous week. Upon receipt of the requested information from the
provider, we must complete processing of the clean claim within 30 business days.
Paper claims that are determined to be unclean will be returned to the billing provider along with a
letter stating the reason for the rejection. Electronic claims that are determined to be unclean will be
returned to the Amerigroup contracted clearinghouse that submitted the claim.
In accordance with state requirements, we will pay at least 90 percent of all clean claims from
practitioners either in individual or group practice or who practice in shared health facilities within 30
days of the date of receipt. We will pay at least 99 percent of all clean claims from practitioners either
in individual or group practice or who practice in shared health facilities within 120 days of the date of
receipt. The date of receipt is the date Amerigroup receives the claim as indicated by its date stamp on
the claim. The date of payment is the date of the check or other form of payment.
Claims Status
You can visit the Amerigroup website located at providers.amerigroup.com/FL or call the automated
Provider Inquiry Line at 1-800-454-3730 to check claims status.
Provider Reimbursement
Increased Medicaid Payments for Primary Care Physicians and Eligible Providers
In compliance with the Patient Protection and Affordable Care Act (PPACA), as amended by Section
1202 of the Health Care and Education Reconciliation Act, Amerigroup reimburses eligible Medicaid
Primary Care Providers (PCPs) at parity with Medicare rates for qualified services in calendar years
2013 and 2014.
If you meet the requirements for the PPACA enhanced physician reimbursement and haven’t yet
submitted a completed attestation, you should do so as soon as possible to qualify for enhanced
payments. Visit https://providers.amerigroup.com/pages/nv-2012.aspx and look in our News &
Announcements section for links to information and instructions to follow or
https://dhcfp.nv.gov/Index.htm.
Amerigroup process for supporting enhanced payments to eligible providers
As set forth in Section 1202 of the PPACA:
 Conditioned upon the state of Florida requiring and providing funding to Amerigroup, Amerigroup
will provide increased reimbursement to Medicare levels or some other federal or state-mandated
level for specified CPT-4 codes for primary care services furnished with dates of service in 2013 and
2014 by providers who have attested to their eligibility to receive such increased reimbursement as
set forth in the Section 1202 of the PPACA.
 Such CPT-4 codes will be paid in accordance with the requirements of PPACA and the State and will
not be subject to any further enhancements from Amerigroup or any other source.
Provider responsibilities with regard to payments
If you completed the attestation process as required by the state, the following procedures and
guidelines apply to you regarding payments received from Amerigroup:
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
If you are a group provider, entity or any person other than the eligible provider who performed
the service, you acknowledge and agree you will direct any and all increased reimbursements to
such eligible providers or otherwise ensure such eligible providers receive direct and full benefit of
the increased reimbursement in accordance with the final rule implementing PPACA. You also
acknowledge and agree you will provide Amerigroup with evidence of your compliance with this
requirement upon request.
Electronic Funds Transfer and Electronic Remittance Advice
Amerigroup offers Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) with online
viewing capability. Providers can elect to receive Amerigroup payments electronically through direct
deposit to their bank accounts. In addition, providers can select from a variety of remittance
information options, including:
 ERA presented online and printed in your location
 HIPAA-compliant data file for download directly to your practice management or patient
accounting system
 Paper remittance printed and mailed by Amerigroup
Some of the benefits providers may experience include:
 Faster receipt of payments from Amerigroup
 The ability to generate custom reports on both payment and claim information based on the
criteria specified
 Online capability to search claims and remittance details across multiple remittances
 Elimination of the need for manual entry of remittance information and user errors
 Ability to perform faster secondary billing
To register for ERA/EFT, please visit our website at providers.amerigroup.com/FL.
PCP Reimbursement
Amerigroup reimburses PCPs according to their contractual arrangement.
Specialist Reimbursement
Reimbursement to network specialty care providers and network providers not serving as PCPs is
based on their contractual arrangement with Amerigroup.
Specialty care providers will obtain PCP and Amerigroup approval prior to rendering or arranging any
treatment that is beyond the specific treatment authorized by the PCP’s referral or beyond the scope
of self-referral permitted under this program.
Specialty care provider services will be covered only when there is documentation of appropriate
notification or precertification and receipt of the required claims and encounter information to
Amerigroup.
Provider Payment Disputes
Providers may access a timely payment dispute resolution process. A payment dispute is any dispute
between the health care provider and Amerigroup for reason(s) including, but not limited to:
 Denials for timely filing
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







Amerigroup failure to pay timely
Contractual payment issues
Lost or incomplete claim forms or electronic submissions
Requests for additional explanation as to services or treatment rendered by a provider
Inappropriate or unapproved referrals initiated by providers (e.g., a provider payment dispute may
arise if a provider was required to get authorization for a service, did not request the authorization,
provided the service and then submitted the claim)
Provider appeals without the member’s consent
Retrospective review after a claim denial or partial payment
Request for supporting documentation
Responses to itemized bill requests, submission of corrected claims and submission of coordination of
benefits/third-party liability information are not considered payment disputes. These are considered
correspondence and should be addressed to Claims Correspondence.
No action is required by the member. Payment disputes do not include medical appeals.
Providers will not be penalized for filing a payment dispute. All information will be confidential. The
Payment Dispute Unit will receive, distribute and coordinate all payment disputes. To submit a
payment dispute, please complete the payment dispute form located in Appendix A — Forms or online
at providers.amerigroup.com/FL and submit to:
Payment Dispute Unit
Amerigroup Community Care
P.O. Box 61599
Virginia Beach, VA 23466-1599
The network provider should file a payment dispute within 120 calendar days of the paid date of the
EOP by submitting a written request with a written explanation of what is in dispute and why. Include
supporting documentation, such as an EOP, a copy of the claim, medical records or contract page.
Non-network providers should file a payment dispute within 120 calendar days of the paid date of the
EOP by submitting a written request with supporting documentation, such as an EOP, a copy of the
claim or medical records.
The Payment Dispute Unit will research and determine the current status of a payment dispute. A
determination will be made based on the available documentation submitted with the dispute and a
review of Amerigroup systems, policies and contracts. Any payment dispute received with supporting
clinical documentation will be retrospectively reviewed by a registered nurse. Established clinical
criteria will be applied to the payment dispute. After retrospective review, the payment dispute may
be approved or forwarded to the plan medical director for further review and resolution.
A Level I determination letter will be sent to the provider within 30 calendar days from receipt of
complete payment dispute information. The response will include the following information:
 Provider name and Amerigroup ID
 Date of initial filing of concern
 Written description of the concern
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
The decision
Further dispute options
If a provider is dissatisfied with the Level I payment dispute resolution, the provider may file a Level II
payment dispute. This should be a written dispute and submitted within 30 days of receipt of the Level
I determination letter.
If a provider is dissatisfied with the Level II payment dispute resolution, the provider may appeal the
Amerigroup decision to Maximus (the vendor for ACHA for provider disputes).
Application forms and instructions on how to file claims are available from Maximus directly. For
information updates, call Maximus at 1-800-356-8151 and ask for the Florida Appeals Process
department.
Coordination of Benefits
State-specific guidelines will be followed when Coordination of Benefits (COB) procedures are
necessary. Amerigroup agrees to use covered medical and hospital services whenever available or
other public or private sources of payment for services rendered to members in the Amerigroup plan.
Amerigroup and our providers agree that the Medicaid program will be the payer of last resort when
third-party resources are available to cover the costs of medical services provided to Medicaid
members. When Amerigroup is aware of these resources prior to paying for a medical service, we will
avoid payment by either rejecting a provider’s claim and redirecting the provider to bill the appropriate
insurance carrier or, if Amerigroup does not become aware of the resource until sometime after
payment for the service was rendered, by pursuing postpayment recovery of the expenditure.
Providers must not seek recovery in excess of the Medicaid payable amount.
Amerigroup will avoid payment of trauma-related claims where third-party resources are identified
prior to payment. Otherwise, we will follow a pay-and-pursue policy on prospective and potential
subrogation cases. Paid claims are reviewed and researched postpayment to determine likely cases
with multiple letters and phone calls being made to document the appropriate details. The filing of
liens and settlement negotiations are handled internally and externally via our subrogation vendor,
ACS Recovery Services.
We will require members to cooperate in the identification of any and all other potential sources of
payment for services.
Any questions or inquiries regarding paid, denied or pended claims should be directed to Provider
Services at 1-800-454-3730.
Billing Members
Overview
Before rendering services, providers should always inform members that the cost of services not
covered by Amerigroup will be charged to the member.
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A provider who chooses to provide services not covered by Amerigroup:
 Understands that Amerigroup only reimburses for services that are medically necessary, including
hospital admissions and other services
 Obtains the member’s signature on the client acknowledgment statement specifying that the
member will be held responsible for payment of services
 Understands that he or she may not bill or take recourse against a member for denied or reduced
claims for services that are within the amount, duration and scope of benefits of the Medicaid
program
Amerigroup members must not be balance-billed for the amount above that which is paid by
Amerigroup for covered services.
In addition, providers may not bill a member if any of the following occurs:
 Failure to submit a claim timely, including claims not received by Amerigroup
 Failure to submit a claim to Amerigroup for initial processing within the six-month filing deadline
 Failure to submit a corrected claim within the 120-day filing resubmission period
 Failure to appeal a claim within the 45-day administrative appeal period
 Failure to appeal a utilization review determination within 30 days of notification of coverage
denial
 Submission of an unsigned or otherwise incomplete claim
 Errors made in claims preparation, claims submission or the appeal process
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Client Acknowledgment Statement
A provider may bill an Amerigroup member for a service that has been denied as not medically
necessary or not a covered benefit only if both of the following conditions are met:
 The member requests the specific service or item
 The provider obtains and keeps a written acknowledgement statement signed by the member and
the provider stating:
“I understand that, in the opinion of (provider’s name), the services or items that I have requested
to be provided to me on (dates of service) may not be covered under Amerigroup as being
reasonable and medically necessary for my care or may not be a covered benefit. I understand that
Amerigroup has established the medical necessity standards for the services or items that I request
and receive. I also understand that I am responsible for payment of the services or items I request
and receive if these services or items are determined to be inconsistent with the Amerigroup
medically necessary standards for my care or are not a covered benefit.”
Signature: _________________________________________________
Date: ___________________________________________________
Amerigroup Website and the Provider Inquiry Line
Amerigroup recognizes that in order for you to provide the best service to our members, we must
share with you accurate, up-to-date information. We offer the following methods of accessing claim
status, member eligibility and authorization determination (24 hours a day, 365 days a year):
 Amerigroup website
 Toll-free, automated Provider Inquiry Line
The Amerigroup website provides a host of online resources at providers.amerigroup.com/FL,
featuring our online provider inquiry tool for real-time claim status, eligibility verification and
precertification status. You can also submit a claim or precertification, print referral forms or
directories, or obtain a member panel listing. Detailed instructions for use of the online provider
inquiry tool can be found on our website.
The toll-free, automated Provider Inquiry Line can be reached at 1-800-454-3730 for real-time
member status, claim status and precertification status. This option also offers the ability to be
transferred to the appropriate department for other needs, such as seeking advice in case/care
management.
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APPENDIX A — FORMS
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Medical Record Forms
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Specialist as PCP Request Form
Date:
____________________________________________________
Member’s Name:
____________________________________________________
Member’s ID:
____________________________________________________
PCP’s Name (if applicable):
____________________________________________________
Specialist/Specialty:
____________________________________________________
Member’s Diagnosis:
____________________________________________________
Describe the medical justification for selecting a specialist as PCP for this member:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The signatures below indicate agreement by the specialist, Amerigroup and the member for
whom the specialist will function as this member’s PCP, including providing to the member
access 24 hours a day, 7 days a week.
Specialist’s Signature: ________________________________
Date: ___________________
Medical Director’s Signature: __________________________
Date: ___________________
Member’s Signature: _________________________________
Date: ___________________
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Precertification Request Form
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Pharmacy Prior Authorization Request Form
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Incident Report Form
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Medical Record Review Checklist
Provider Name: ______________________________________________ Date of Review: _____________________
Specialty: ________________________________________________ Reviewer: ________________________________
Check One: Audit _____ Credentialing Visit _____ Recredentialing Visit ______
Member Name
Date of birth
Member ID
CRITERIA (Critical indicators are in bold type)
Y
N
N/A
1. Patient identification on each page
2. Biographical/personal data documented
3. Medical record entries are legible
4. All entries dated and signed by provider
5. Medication log
6. Immunization log up to date
7. Immunization log complete (route, dose, lot
number, expiration date)
8. Immunization log signed by appropriate provider
9. Allergies and adverse reactions flagged
10. Completed problem list
11. Past medical history
12. Follow-up on past visit problems
13. Mental health screening
13. Psychosocial assessment
14. EtOH/substance/smoking screen counseling
15. HIV education, counseling and screening
16. Domestic violence/child abuse screening
17. Pertinent history and physical exam
18. Working diagnosis consistent with findings
19. Tx plan appropriate and consistent with Dx
20. Return date and follow-up plan on encounter
with time
21. Labs and other studies as appropriate
22. Labs and other studies reviewed and initialed
23. Appropriate use of specialist/consultants
24. Continuity and coordination of care with
specialist
25. Consultative reports reviewed and initialed
26. Preventive services rendered appropriately
27. Age-appropriate education provided
28. Appropriate reporting of communicable disease
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Y
N
N/A
Y
N
N/A
Y
N
N/A
Medical Documentation Forms
2-5 Days Documentation
1 Month Documentation
2 Month Documentation
4 Month Documentation
6 Month Documentation
9 Month Documentation
12 Month Documentation
15 Month Documentation
18 Month Documentation
2 Year Documentation
2.5 Year Documentation
3 Year Documentation
4 Year Documentation
5-6 Year Documentation
7-8 Year Documentation
9-10 Year Documentation
11-14 Year Documentation
15-21 Year Documentation
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Pediatric Periodicity Forms
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American Academy of Pediatrics – Bright Futures Periodicity Schedule
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U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
American College of Obstetricians and Gynecologists
(http://www.acog.org)
American Academy of Family Physicians
(http://www.aafp.org)
American Academy of Pediatrics
(http://www.aap.org)
Advisory Committee on Immunization Practices
(http://www.cdc.gov/vaccines/acip)
The Recommended Immunization Schedules for
Persons Aged 0 Through 18 Years are approved by the
This schedule includes recommendations in effect as of January 1, 2014. Any dose not administered at the
recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a
combination vaccine generally is preferred over separate injections of its equivalent component vaccines.
Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement
for detailed recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically
significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting
System ( VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).
Recommended Immunization Schedules for Persons Aged 0 Through 18 Years
UNITED STATES, 2014
7-10 yrs
(Tdap)
11-12 yrs
2nd dose
2nd dose
Annual vaccination (IIV or LAIV)
4th dose
5th dose
4-6 yrs
Range of recommended
ages for certain high-risk
groups
Not routinely
recommended
13–15
yrs
Booster
16–18
yrs
NOTE: The above recommendations must be read along with the footnotes of this schedule.
This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (http://www.aap.org), the American Academy of Family Physicians
(http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).
This schedule includes recommendations in effect as of January 1, 2014. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination
vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed
recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System
( VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including
precautions and contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm) or by telephone (800-CDC-INFO [800-232-4636]).
Range of
recommended ages for
all children
1st dose
Meningococcal1 3 (Hib-MenCY > 6 weeks; MenACWY-D
>9 mos; MenACWY-CRM
≥ 2 mos)
Range of recommended ages
during which catch-up is
encouraged and for certain
high-risk groups
2-3 yrs
(3-dose
series)
2-dose series, See footnote 11
19–23
mos
Human papillomavirus1 2
(HPV2: females only; HPV4:
males and females)
Hepatitis A11 (HepA)
See footnote 13
Annual vaccination (IIV only)
3rd dose
4th dose
18 mos
4th dose
15 mos
3rd or 4th dose,
See footnote 5
3rd dose
12 mos
1st dose
9 mos
Varicella1 0 (VAR)
3rd dose
See
footnote 5
3rd dose
See
footnote 2
6 mos
1st dose
Range of recommended
ages for catch-up
immunization
2nd dose
2nd dose
2nd dose
2nd dose
2nd dose
4 mos
Measles, mumps, rubella9
(MMR)
Influenza8 (IIV; LAIV) 2 doses
for some: See footnote 8
Inactivated poliovirus7 (IPV)
(<18 yrs)
1st dose
1st dose
Pneumococcal conjugate6
(PCV13)
Pneumococcal polysaccharide6 (PPSV23)
1st dose
Haemophilus influenzae type
b5 (Hib)
Tetanus, diphtheria, & acellular pertussis4 (Tdap: >7 yrs)
1st dose
Diphtheria, tetanus, & acellular pertussis3 (DTaP: <7 yrs)
2nd dose
2 mos
1st dose
1st dose
Hepatitis B1 (HepB)
1 mo
Rotavirus2 (RV) RV1 (2-dose
series); RV5 (3-dose series)
Birth
Vaccine
Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – United States, 2014.
(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1.
To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are in bold.
6 weeks
6 weeks
6 weeks
6 weeks
6 weeks
12
months
12 months
Diphtheria, tetanus, &
acellular pertussis 3
Haemophilus
influenzae type b5
Pneumococcal6
Inactivated poliovirus7
Meningococcal13
Measles, mumps,
rubella9
Varicella10
6 weeks
4 weeks if first dose administered at younger than age
12 months
8 weeks (as final dose for healthy children) if first dose
administered at age 12 months or older
No further doses needed for healthy children if first dose
administered at age 24 months or older
3 months if person is younger than age 13 years
4 weeks if person is aged 13 years or older
12
months
Varicella10
4 weeks7
8 weeks (and at least 16 weeks after first dose)
Routine dosing intervals are recommended12
4 weeks if first dose of DTaP/DT administered at younger than
age 12 months
6 months if first dose of DTaP/DT administered at age 12
months or older and then no further doses needed for catch-up
Persons aged 7 through 18 years
See footnote 13
NOTE: The above recommendations must be read along with the footnotes of this schedule.
4 weeks
12 months
Measles, mumps,
rubella9
8 weeks13
6 weeks
4 weeks
4 weeks
6 months
4 weeks
6 months
3 months
4 weeks
8
weeks13
4 weeks7
4 weeks if current age is younger than 12 months
8 weeks (as final dose for healthy children) if current age is 12
months or older
No further doses needed for healthy children if previous dose
administered at age 24 months or older
4 weeks if first dose administered at younger than age
12 months
8 weeks (as final dose)
if first dose administered at age 12 through 14 months
No further doses needed
if first dose administered at age 15 months or older
4 weeks7
8 weeks (as final dose)
This dose only necessary for children aged 12 through
59 months who received 3 (PRP-T) doses before age
12 months and started the primary series before age
7 months
4 weeks5 if current age is younger than 12 months and first
dose administered at < 7 months old
8 weeks and age 12 months through 59 months (as final
dose)5 if current age is younger than 12 months and first dose
administered between 7 through 11 months (regardless of Hib
vaccine [PRP-T or PRP-OMP] used for first dose); OR
if current age is 12 through 59 months and first dose
administered at younger than age 12 months; OR
first 2 doses were PRP-OMP and administered at younger than
12 months.
No further doses needed if previous dose administered at age
15 months or older
6 months7
6 months if first dose of DTaP/DT administered at
younger than age 12 months
See footnote 13
6 months7 minimum age 4 years for final dose
8 weeks (as final dose)
This dose only necessary for children aged 12 through
59 months who received 3 doses before age 12
months or for children at high risk who received 3
doses at any age
6 months
Dose 3 to dose 4
4 weeks
4 weeks2
8 weeks and at least 16 weeks after first dose; minimum age
for the final dose is 24 weeks
Dose 2 to dose 3
Minimum Interval Between Doses
4 weeks
4 weeks
4 weeks
Dose 1 to dose 2
Meningococcal13
Inactivated
Hepatitis
Birth
12 months
Hepatitis A11
poliovirus7
9 years
Human papillomavirus12
B1
7 years4
Tetanus, diphtheria;
tetanus, diphtheria, &
acellular pertussis4
12 months
6 weeks
Rotavirus2
Hepatitis
Birth
Hepatitis B1
A11
Minimum
Age for
Dose 1
Vaccine
Persons aged 4 months through 6 years
6 months3
Dose 4 to dose 5
FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —United States, 2014.
The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless of the time
that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in conjunction with Figure 1 and the footnotes that follow.
2.
1.
Hepatitis B (HepB) vaccine. (Minimum age: birth)
Routine vaccination:
At bir th:
• Administer monovalent HepB vaccine to all newborns before hospital discharge.
• For infants born to hepatitis B surface antigen (HBsAg)-positive mothers, administer HepB vaccine and
0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested
for HBsAg and antibody to HBsAg (anti-HBs) 1 to 2 months after completion of the HepB series, at age
9 through 18 months (preferably at the next well-child visit).
• If mother ’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine regardless of
birth weight. For infants weighing less than 2,000 grams, administer HBIG in addition to HepB vaccine
within 12 hours of birth. Determine mother’s HBsAg status as soon as possible and, if mother is HBsAgpositive, also administer HBIG for infants weighing 2,000 grams or more as soon as possible, but no
later than age 7 days.
Doses following the bir th dose:
• The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be
used for doses administered before age 6 weeks.
• Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a
schedule of 0, 1 to 2 months, and 6 months starting as soon as feasible. See Figure 2.
• Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks),
administer the third dose at least 8 weeks after the second dose AND at least 16 weeks after the first
dose. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than
age 24 weeks.
• Administration of a total of 4 doses of HepB vaccine is permitted when a combination vaccine
containing HepB is administered after the birth dose.
Catch-up vaccination:
• Unvaccinated persons should complete a 3-dose series.
• A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed
for use in children aged 11 through 15 years.
• For other catch-up guidance, see Figure 2.
Rotavirus (RV ) vaccines. (Minimum age: 6 weeks for both RV1 [Rotarix] and RV5 [RotaTeq])
Routine vaccination:
Administer a series of RV vaccine to all infants as follows:
1. If Rotarix is used, administer a 2-dose series at 2 and 4 months of age.
2. If RotaTeq is used, administer a 3-dose series at ages 2, 4, and 6 months.
3. If any dose in the series was RotaTeq or vaccine product is unknown for any dose in the series, a total
of 3 doses of RV vaccine should be administered.
Catch-up vaccination:
• The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be
initiated for infants aged 15 weeks, 0 days or older.
• The maximum age for the final dose in the series is 8 months, 0 days.
• For other catch-up guidance, see Figure 2.
5.
4.
3.
Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks.
Exception: DTaP-IPV [Kinrix]: 4 years)
Routine vaccination:
• Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15 through 18 months, and 4 through 6 years.
The fourth dose may be administered as early as age 12 months, provided at least 6 months have
elapsed since the third dose.
Catch-up vaccination:
• The fifth dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older.
• For other catch-up guidance, see Figure 2.
Tetanus and diphtheria toxoids and acellular pertussis ( Tdap) vaccine. (Minimum age: 10 years for
Boostrix, 11 years for Adacel)
Routine vaccination:
• Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years.
• Tdap may be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine.
• Administer 1 dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during
27 through 36 weeks gestation) regardless of time since prior Td or Tdap vaccination.
Catch-up vaccination:
• Persons aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap
vaccine as 1 (preferably the first) dose in the catch-up series; if additional doses are needed, use Td
vaccine. For children 7 through 10 years who receive a dose of Tdap as part of the catch-up series, an
adolescent Tdap vaccine dose at age 11 through 12 years should NOT be administered. Td should be
administered instead 10 years after the Tdap dose.
• Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed
by tetanus and diphtheria toxoids ( Td) booster doses every 10 years thereafter.
• Inadvertent doses of DTaP vaccine:
- If administered inadvertently to a child aged 7 through 10 years may count as part of the catch-up
series. This dose may count as the adolescent Tdap dose, or the child can later receive a Tdap
booster dose at age 11 through 12 years.
- If administered inadvertently to an adolescent aged 11 through 18 years, the dose should be
counted as the adolescent Tdap booster.
• For other catch-up guidance, see Figure 2.
Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks for PRP-T [ACTHIB,
DTaP-IPV/Hib (Pentacel) and Hib-MenCY (MenHibrix)], PRP-OMP [PedvaxHIB or COMVAX], 12 months
for PRP-T [Hiberix])
Routine vaccination:
• Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4 depending on
vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series.
• The primary series with ActHIB, MenHibrix, or Pentacel consists of 3 doses and should be administered
at 2, 4, and 6 months of age. The primary series with PedvaxHib or COMVAX consists of 2 doses and
should be administered at 2 and 4 months of age; a dose at age 6 months is not indicated.
• One booster dose (dose 3 or 4 depending on vaccine used in primary series) of any Hib vaccine should
be administered at age 12 through 15 months. An exception is Hiberix vaccine. Hiberix should only
be used for the booster (final) dose in children aged 12 months through 4 years who have received at
least 1 prior dose of Hib-containing vaccine.
Additional information
• For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online
at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
• For purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months.
• Vaccine doses administered 4 days or less before the minimum interval are considered valid. Doses of any vaccine administered ≥5 days earlier than the minimum interval or minimum age
should not be counted as valid doses and should be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. For further
details, see MMWR, General Recommendations on Immunization and Reports / Vol. 60 / No. 2; Table 1. Recommended and minimum ages and intervals between vaccine doses available online at
http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
• Information on travel vaccine requirements and recommendations is available at http://wwwnc.cdc.gov/travel/destinations/list.
• For vaccination of persons with primary and secondary immunodeficiencies, see Table 13, “Vaccination of persons with primary and secondary immunodeficiencies,” in General Recommendations
on Immunization (ACIP), available at http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.; and American Academy of Pediatrics. Immunization in Special Clinical Circumstances, in Pickering LK, Baker CJ,
Kimberlin DW, Long SS eds. Red Book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics.
For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
For vaccine recommendations for persons 19 years of age and older, see the adult immunization schedule.
Footnotes — Recommended immunization schedule for persons aged 0 through 18 years—United States, 2014
6.
5.
Haemophilus influenzae type b (Hib) conjugate vaccine (cont’d)
• For recommendations on the use of MenHibrix in patients at increased risk for meningococcal disease,
please refer to the meningococcal vaccine footnotes and also to MMWR March 22, 2013; 62(RR02);1-22,
available at http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf.
Catch-up vaccination:
• If dose 1 was administered at ages 12 through 14 months, administer a second (final) dose at least 8
weeks after dose 1, regardless of Hib vaccine used in the primary series.
• If the first 2 doses were PRP-OMP (PedvaxHIB or COMVAX), and were administered at age 11 months or
younger, the third (and final) dose should be administered at age 12 through 15 months and at least 8
weeks after the second dose.
• If the first dose was administered at age 7 through 11 months, administer the second dose at least 4
weeks later and a third (and final) dose at age 12 through 15 months or 8 weeks after second dose,
whichever is later, regardless of Hib vaccine used for first dose.
• If first dose is administered at younger than 12 months of age and second dose is given between 12
through 14 months of age, a third (and final) dose should be given 8 weeks later.
• For unvaccinated children aged 15 months or older, administer only 1 dose.
• For other catch-up guidance, see Figure 2. For catch-up guidance related to MenHibrix, please see the
meningococcal vaccine footnotes and also MMWR March 22, 2013; 62(RR02);1-22, available at
http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf.
Vaccination of persons with high-risk conditions:
• Children aged 12 through 59 months who are at increased risk for Hib disease, including
chemotherapy recipients and those with anatomic or functional asplenia (including sickle cell disease),
human immunodeficiency virus (HIV ) infection, immunoglobulin deficiency, or early component
complement deficiency, who have received either no doses or only 1 dose of Hib vaccine before 12
months of age, should receive 2 additional doses of Hib vaccine 8 weeks apart; children who received
2 or more doses of Hib vaccine before 12 months of age should receive 1 additional dose.
• For patients younger than 5 years of age undergoing chemotherapy or radiation treatment who
received a Hib vaccine dose(s) within 14 days of starting therapy or during therapy, repeat the dose(s)
at least 3 months following therapy completion.
• Recipients of hematopoietic stem cell transplant (HSCT ) should be revaccinated with a 3-dose regimen
of Hib vaccine starting 6 to 12 months after successful transplant, regardless of vaccination history;
doses should be administered at least 4 weeks apart.
• A single dose of any Hib-containing vaccine should be administered to unimmunized* children and
adolescents 15 months of age and older undergoing an elective splenectomy; if possible, vaccine
should be administered at least 14 days before procedure.
• Hib vaccine is not routinely recommended for patients 5 years or older. However, 1 dose of Hib vaccine
should be administered to unimmunized* persons aged 5 years or older who have anatomic or
functional asplenia (including sickle cell disease) and unvaccinated persons 5 through 18 years of age
with human immunodeficiency virus (HIV ) infection.
* Patients who have not received a primar y series and booster dose or at least 1 dose of Hib vaccine
after 14 months of age are considered unimmunized.
Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23)
Routine vaccination with PCV13:
• Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months.
• For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV
(PCV7), administer a single supplemental dose of 13-valent PCV (PCV13).
Catch-up vaccination with PC V13:
• Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not
completely vaccinated for their age.
• For other catch-up guidance, see Figure 2.
Vaccination of persons with high-risk conditions with PCV13 and PPSV23:
• All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible.
• For children 2 through 5 years of age with any of the following conditions: chronic heart disease
(particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including
asthma if treated with high-dose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid
leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional
asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment
with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias,
lymphomas, and Hodgkin disease; solid organ transplantation; or congenital immunodeficiency:
1. Administer 1 dose of PCV13 if 3 doses of PCV (PCV7 and/or PCV13) were received previously.
2. Administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV (PCV7 and/or PCV13)
were received previously.
8.
7.
6.
Pneumococcal vaccines (cont’d)
3. Administer 1 supplemental dose of PCV13 if 4 doses of PCV7 or other age-appropriate complete PCV7
series was received previously.
4. The minimum interval between doses of PCV (PCV7 or PCV13) is 8 weeks.
5. For children with no history of PPSV23 vaccination, administer PPSV23 at least 8 weeks after the most
recent dose of PCV13.
• For children aged 6 through 18 years who have cerebrospinal fluid leak; cochlear implant; sickle cell disease
and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired immunodeficiencies;
HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with
immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and
Hodgkin disease; generalized malignancy; solid organ transplantation; or multiple myeloma:
1. If neither PCV13 nor PPSV23 has been received previously, administer 1 dose of PCV13 now and 1
dose of PPSV23 at least 8 weeks later.
2. If PCV13 has been received previously but PPSV23 has not, administer 1 dose of PPSV23 at least 8
weeks after the most recent dose of PCV13.
3. If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the
most recent dose of PPSV23.
• For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart
disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral
corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received
PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be
administered at least 8 weeks after any prior PCV13 dose.
• A single revaccination with PPSV23 should be administered 5 years after the first dose to children
with sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital
or acquired immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases
associated with treatment with immunosuppressive drugs or radiation therapy, including malignant
neoplasms, leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ
transplantation; or multiple myeloma.
Inactivated poliovirus vaccine (IPV ). (Minimum age: 6 weeks)
Routine vaccination:
• Administer a 4-dose series of IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years. The final
dose in the series should be administered on or after the fourth birthday and at least 6 months after
the previous dose.
Catch-up vaccination:
• In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk
for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
• If 4 or more doses are administered before age 4 years, an additional dose should be administered at
age 4 through 6 years and at least 6 months after the previous dose.
• A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6
months after the previous dose.
• If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless
of the child’s current age. IPV is not routinely recommended for U.S. residents aged 18 years or older.
• For other catch-up guidance, see Figure 2.
Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV ], 2 years for live,
attenuated influenza vaccine [LAIV ])
Routine vaccination:
• Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy,
nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should
NOT be administered to some persons, including 1) those with asthma, 2) children 2 through 4 years who
had wheezing in the past 12 months, or 3) those who have any other underlying medical conditions that
predispose them to influenza complications. For all other contraindications to use of LAIV, see MMWR
2013; 62 (No. RR-7):1-43, available at http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf.
For children aged 6 months through 8 years:
• For the 2013–14 season, administer 2 doses (separated by at least 4 weeks) to children who are
receiving influenza vaccine for the first time. Some children in this age group who have been
vaccinated previously will also need 2 doses. For additional guidance, follow dosing guidelines in the
2013-14 ACIP influenza vaccine recommendations, MMWR 2013; 62 (No. RR-7):1-43, available at
http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf.
• For the 2014–15 season, follow dosing guidelines in the 2014 ACIP influenza vaccine
recommendations.
For persons aged 9 years and older:
• Administer 1 dose.
For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
12.
11.
10.
9.
Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)
Routine vaccination:
• Administer a 2-dose series of MMR vaccine at ages12 through 15 months and 4 through 6 years. The second
dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose.
• Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the
United States for international travel. These children should be revaccinated with 2 doses of MMR
vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease
risk is high), and the second dose at least 4 weeks later.
• Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the
United States for international travel. The first dose should be administered on or after age 12 months
and the second dose at least 4 weeks later.
Catch-up vaccination:
• Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum
interval between the 2 doses is 4 weeks.
Varicella ( VAR) vaccine. (Minimum age: 12 months)
Routine vaccination:
• Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The
second dose may be administered before age 4 years, provided at least 3 months have elapsed since
the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be
accepted as valid.
Catch-up vaccination:
• Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007; 56
[No. RR-4], available at http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf ) have 2 doses of varicella vaccine.
For children aged 7 through 12 years, the recommended minimum interval between doses is 3 months
(if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid);
for persons aged 13 years and older, the minimum interval between doses is 4 weeks.
Hepatitis A (HepA) vaccine. (Minimum age: 12 months)
Routine vaccination:
• Initiate the 2-dose HepA vaccine series at 12 through 23 months; separate the 2 doses by 6 to 18 months.
• Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose
6 to 18 months after the first dose.
• For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of
HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus
infection is desired.
Catch-up vaccination:
• The minimum interval between the two doses is 6 months.
Special populations:
• Administer 2 doses of HepA vaccine at least 6 months apart to previously unvaccinated persons who
live in areas where vaccination programs target older children, or who are at increased risk for infection.
This includes persons traveling to or working in countries that have high or intermediate endemicity of
infection; men having sex with men; users of injection and non-injection illicit drugs; persons who work
with HAV-infected primates or with HAV in a research laboratory; persons with clotting-factor disorders;
persons with chronic liver disease; and persons who anticipate close, personal contact (e.g., household
or regular babysitting) with an international adoptee during the first 60 days after arrival in the United
States from a country with high or intermediate endemicity. The first dose should be administered as
soon as the adoption is planned, ideally 2 or more weeks before the arrival of the adoptee.
Human papillomavirus (HPV ) vaccines. (Minimum age: 9 years for HPV2 [Cervarix] and HPV4
[Gardasil])
Routine vaccination:
• Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11
through 12 years. Either HPV4 or HPV2 may be used for females, and only HPV4 may be used for males.
• The vaccine series may be started at age 9 years.
• Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks),
administer the third dose 24 weeks after the first dose and 16 weeks after the second dose (minimum
interval of 12 weeks).
Catch-up vaccination:
• Administer the vaccine series to females (either HPV2 or HPV4) and males (HPV4) at age 13 through 18
years if not previously vaccinated.
• Use recommended routine dosing intervals (see above) for vaccine series catch-up.
13.
For complete information on use of meningococcal vaccines, including guidance related to
vaccination of persons at increased risk of infec tion, see MMWR March 22, 2013; 62(RR02);1-22,
available at http://w w w.cdc.gov/mmwr/pdf/rr/rr6202.pdf.
Meningococcal conjugate vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 9 months for
MenACWY-D [Menactra], 2 months for MenACWY-CRM [Menveo])
Routine vaccination:
• Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster
dose at age 16 years.
• Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV ) infection should
receive a 2-dose primary series of Menactra or Menveo with at least 8 weeks between doses.
• For children aged 2 months through 18 years with high-risk conditions, see below.
Catch-up vaccination:
• Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated.
• If the first dose is administered at age 13 through 15 years, a booster dose should be administered at
age 16 through 18 years with a minimum interval of at least 8 weeks between doses.
• If the first dose is administered at age 16 years or older, a booster dose is not needed.
• For other catch-up guidance, see Figure 2.
Vaccination of persons with high-risk conditions and other persons at increased risk of disease:
• Children with anatomic or functional asplenia (including sickle cell disease):
1. For children younger than 19 months of age, administer a 4-dose infant series of MenHibrix or Menveo
at 2, 4, 6, and 12 through 15 months of age.
2. For children aged 19 through 23 months who have not completed a series of MenHibrix or Menveo,
administer 2 primary doses of Menveo at least 3 months apart.
3. For children aged 24 months and older who have not received a complete series of MenHibrix or
Menveo or Menactra, administer 2 primary doses of either Menactra or Menveo at least 2 months apart.
If Menactra is administered to a child with asplenia (including sickle cell disease), do not administer
Menactra until 2 years of age and at least 4 weeks after the completion of all PCV13 doses.
• Children with persistent complement component deficiency:
1. For children younger than 19 months of age, administer a 4-dose infant series of either MenHibrix or
Menveo at 2, 4, 6, and 12 through 15 months of age.
2. For children 7 through 23 months who have not initiated vaccination, two options exist depending
on age and vaccine brand:
a. For children who initiate vaccination with Menveo at 7 months through 23 months of age, a 2-dose
series should be administered with the second dose after 12 months of age and at least 3 months
after the first dose.
b. For children who initiate vaccination with Menactra at 9 months through 23 months of age, a 2-dose
series of Menactra should be administered at least 3 months apart.
c. For children aged 24 months and older who have not received a complete series of MenHibrix,
Menveo, or Menactra, administer 2 primary doses of either Menactra or Menveo at least 2 months
apart.
• For children who travel to or reside in countries in which meningococcal disease is hyperendemic
or epidemic, including countries in the African meningitis belt or the Hajj, administer an age appropriate formulation and series of Menactra or Menveo for protection against serogroups A and
W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children traveling to the
meningitis belt or the Hajj because it does not contain serogroups A or W.
• For children at risk during a community outbreak attributable to a vaccine serogroup, administer or
complete an age- and formulation-appropriate series of MenHibrix, Menactra, or Menveo.
• For booster doses among persons with high-risk conditions, refer to MMWR 2013; 62(RR02);1-22,
available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6202a1.htm.
Catch-up recommendations for persons with high-risk conditions:
1. If MenHibrix is administered to achieve protection against meningococcal disease, a complete ageappropriate series of MenHibrix should be administered.
2. If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at
least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease.
3. For children who initiate vaccination with Menveo at 7 months through 9 months of age, a 2-dose
series should be administered with the second dose after 12 months of age and at least 3 months
after the first dose.
4. For other catch-up recommendations for these persons, refer to MMWR 2013; 62(RR02);1-22, available
at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6202a1.htm.
For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
HIV Antibody Blood Forms
The rest of this page intentionally left blank. Form displayed on subsequent pages.
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Counsel for HIV Antibody Blood Test
use patient imprint
Name: _______________________________________________________________________
In accordance with Chapter 174, P.L. 1995:
I acknowledge that ____________________________________________ has counseled
(Name of physician or other provider)
and provided me with:
A. Information concerning how HIV is transmitted
B. The benefits of voluntary testing
C. The benefits of knowing if I have HIV or not
D. The treatments which are available to me and my unborn child should I test positive
E. The fact that I have a right to refuse the test and I will not be denied treatment
I have consented to be tested for infection with HIV.
I have decided not to be tested for infection with HIV.
This record will be retained as a permanent part of the patient’s medical record.
______________________________________
Signature of Patient
____________________________
Date
______________________________________
Signature of Witness
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Consent for the HIV Antibody Blood Test
I have been told that my blood will be tested for antibodies to the virus named HIV (Human
Immunodeficiency Virus). This is the virus that causes AIDS (Acquired Immunodeficiency Syndrome),
but it is not a test for AIDS. I understand that the test is done on blood.
I have been advised that the test is not 100 percent accurate. The test may show that a person has
antibodies to the virus when they really don’t — this is a false-positive test. The test may also fail to
show that a person has antibodies to the virus when they really do — this is a false-negative test. I
have also been advised that this is not a test for AIDS and that a positive test does not mean that I have
AIDS. Other tests and examinations are needed to diagnose AIDS.
I have been advised that if I have any questions about the HIV antibody test, its benefits or its risks, I
may ask those questions before I decide to agree to the blood test.
I understand that the results of this blood test will only be given to those health care workers directly
responsible for my care and treatment. I also understand that my results can only be given to other
agencies or persons if I sign a release form.
By signing below, I agree that I have read this form or someone has read this form to me. I have had all
my questions answered and have been given all the information I want about the blood test and the
use of the results of my blood test. I agree to give a tube of blood for the HIV antibody tests. There is
almost no risk in giving blood. I may have some pain or a bruise around the place that the blood was
taken.
___________________________________ __________________________________
Date
Patient’s/Guardian’s Signature
___________________________________ ___________________________________
Witness Signature
Patient’s/Guardian’s Printed Name
____________________________________
Physician Signature
Amerigroup recognizes the need for strict confidentiality guidelines.
FL-PM-0024-14
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Results of the HIV Antibody Blood Test
A. EXPLANATION
This authorization for use or disclosure of the results of a blood test to detect antibodies to HIV, the
probable causative agent of Acquired Immunodeficiency Syndrome (AIDS), is being requested of you to
comply with the terms of Confidentiality of Medical Information Act, Civil Code Section 56 et seq. and
Health and Safety Code Section 199.21(g).
B. AUTHORIZATION
I hereby authorize _____________________________________________________ to furnish
(Name of physician, hospital or health care provider)
to ________________________________________________________ the results of the blood
(Name or title of person who is to receive results)
test for antibodies to HIV.
C. USES
The requester may use the information for any purpose, subject only to the following limitation:
____________________________________________________________________.
D. DURATION
This authorization shall become effective immediately and shall remain in effect indefinitely or until
________________________, 20____, whichever is shorter.
E. RESTRICTIONS
I understand that the requester may not further use or disclose the medical information unless another
authorization is obtained from me or unless such use or disclosure is specifically required or permitted
by law.
F. ADDITIONAL COPY
I further understand that I have a right to receive a copy of this authorization upon my request. Copy
requested and received:
Yes
No _______________ Initial
Date: ______________, 20________ ________________________________________
Signature
_________________________________________
Printed Name
This form must be in at least eight-point type.
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Hysterectomy and Sterilization Forms
Visit the U.S. Department of Health & Human Services located at www.hhs.gov/forms to access the
hysterectomy and sterilization forms.
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Sterilization Consent Form
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Hysterectomy Acknowledgement Form
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Abortion Certification Form
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Durable Power of Attorney (English)
_________________________________________
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Durable Power of Attorney (Spanish)
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Living Will (Florida Declaration)
On this ___ day of _____, 20__, I, _________________________________________________,
Last Name
First Name
MI
of my own free will, make known my desire that my dying not be artificially prolonged under any of the
circumstances set out below, and I do hereby declare that:
Should I develop a terminal condition, and if my attending physician determines there can be no
reasonable expectation of recovery from such a condition and my death is imminent, I hereby direct
that life-prolonging procedures be withheld or withdrawn when such procedures serve only to
artificially prolong the process of my dying. Under such circumstances, it is my desire that I be
permitted to die naturally, with only the administration of such medication or the performance of any
such medical procedure judged necessary to provide me with comfort and pain relief.
Relating to the administration of nutrition and hydration (food and fluids), I do __/I do not __ (check
one) desire that such be withheld or withdrawn when such procedures serve to only prolong in an
artificial way the process of my dying. It is my intent that, should I be unable to give directions
regarding the use of life-prolonging procedures, this represents the declaration of my intent and will be
honored by my physicians, as well as by my family, as a valid representation of my legal right to refuse
medical and/or surgical treatment and to accept the consequences as such.
I fully understand the important and consequences of this declaration. I am competent to make such
declaration, and it is my desire to do so. I make this declaration without coercion and of my own free
will.
If I am diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall not be
in effect during the course of my pregnancy.
Check one:
 I want to donate my organs.
 I do not want to donate my organs.
Signature: ________________________________________ Date: _______________________
Declaration of Witness:
The above is known to me, and it is my judgment that he/she is of sound mind and is making the above
declaration of his/her free will.
Witness 1: ______________________________ Relationship: ___________________________
Witness 2: ______________________________ Relationship: ___________________________
Note: One witness should neither be a spouse nor a blood relative of the declarant, in compliance with Florida Statute 765,
amended effective 10/1/90.
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Testamento Médico en Vida (Declaración de Florida)
En este día ___ de _____de 20__, Yo, ______________________________________________,
Apellido
Primer nombre
Inicial del segundo nombre
por voluntad propia quiero manifestar (por escrito) mi deseo, de que mi vida no sea prolongada
artificialmente bajo ninguna de las circunstancias dispuestas a continuación en este documento y por
consiguiente declaro:
Si desarrollo una condición terminal y el médico que me atiende considera que no hay expectativa
razonable de recuperación debido a esta condición y mi muerte es inminente, declaro directamente
que los procedimientos para prolongar mi vida sean evitados o retirados cuando dichos
procedimientos sirvan solamente para prolongar artificialmente el proceso de mi muerte. Bajo éstas
circunstancias, es mi deseo el que se me permita morir naturalmente, que solamente se me
administren medicamentos o se ejecuten procedimientos que se juzguen necesarios para proveerme
comodidad y aliviar el dolor. Con relación a la nutrición e hidratación (alimentos y fluidos) Yo deseo
____/Yo no deseo (marque una de las dos opciones) que éstos procedimientos me sean negados o
reservados cuando éstos solamente sirvan para prolongar de forma artificial el proceso de mi muerte.
Es mi intención que si de alguna forma quedo impedido de dar las direcciones referentes a
procedimientos de prolongar la vida, sea esta declaración la representación de mi intención que será
honrada por mis médicos, así como mi familia como representación de mis derechos legales de rehusar
tratamientos médicos y/o quirúrgicos y aceptar las consecuencias como tales.
Es de mi absoluto entendimiento la importancia y consecuencias de ésta declaración y es mi deseo de
que así sea. Hago esta declaración sin coacción y por voluntad propia.
Si llega a haber un diagnóstico de embarazo y mi médico tiene conocimiento del mismo, esta
declaración no se hará efectiva durante el curso de mi embarazo.
Marque una de las dos opciones:  Yo deseo donar mis órganos.  Yo no deseo donar mis órganos.
Firma: ___________________________________________ Fecha: _______________________
Declaración de Testigos:
Lo arriba escrito es de mi conocimiento y a mi juicio el/ella está en su sano juicio y está haciendo esta
declaración voluntariamente.
Testigo 1: __________________________________ Relación: ___________________________
Testigo 2: __________________________________ Relación: ___________________________
Nota: Uno de los testigos no debe ser cónyuge o pariente consanguíneo del declarante de acuerdo con
el Estatuto 765 de la Florida, enmienda efectiva 10/1/90.
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Advance Directive (English)
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Advance Directive (Spanish)
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Provider Payment Dispute and Correspondence Form
Provider Payment Dispute and Correspondence – Submission Form
This form should be completed by providers for payment disputes and claim correspondence only.
Member First and Last Name_________________________________________ Member DOB
Member Amerigroup, Medicaid or Medicare ID (circle one) ______________________________________
Provider First and Last Name________________________ National Provider Identifier (NPI)_______________
Participating
Nonparticipating*
*If filing for a Medicare member and the member has potential financial liability, you must include a completed CMS
Waiver of Liability form.
Provider Contact First and Last Name________________________________ Contact Phone (____) ______ _______
Provider Street Address_________________________________________________________________________
City_______________________ State______ ZIP_____________ Phone (_______) ________________________
Claim Number________________________ Billed Amount $____________ Amount Received $__________________
Start Date of Service _________________ End Date of Service ________________
Auth Number _____________
To ensure timely and accurate processing of your request, please complete the payment dispute or claim
correspondence section below by checking () the applicable determination or request reason that was provided on
the Amerigroup determination letter or Explanation of Payment (EOP).
PAYMENT DISPUTE: Check () One →
First-level Dispute
Second-level Dispute
A payment dispute is defined as a dispute between the provider and Amerigroup in reference to a claim determination
where the member cannot be held financially liable. All disputes with member liability must follow the applicable
appeals process. Please refer to the EOP to ensure you are following the correct process.
Clearly and completely indicate the payment dispute reason(s). You may attach an additional sheet if necessary.
Please include appropriate medical records.
__________________________________________________________________________________________
CLAIM CORRESPONDENCE: Check () appropriate box below.
Claim correspondence is defined as a request for additional/needed information in order for a claim to be considered
clean, to be processed correctly or for a payment determination to be made.
Itemized Bill/Medical Records (In response to an Amerigroup claim denial or request)
Corrected Claim
Other Insurance/Third-Party Liability Information
Other Correspondence
Clearly and completely indicate the reason(s) for your correspondence. You may attach an additional sheet if necessary.
____________________________________________________________________________________
Mail this form and supporting documentation to:
Payment Disputes
Amerigroup Community Care
P.O. Box 61599
Virginia Beach, VA 23466-1599
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APPENDIX B — CLINICAL PRACTICE GUIDELINES
Visit our website at providers.amerigroup.com/FL for the clinical practice guidelines.
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ADDITIONAL FORMS
The following forms are also available on our website at providers.amerigroup.com/FL. You may also
download them for your use as needed.
Medicare Forms
 CMS Waiver of Liability Statement
 Medicare Advantage Health Risk Assessment Form
Referral and Claim Submission Forms
 Authorization Request Form
 Maternity Notification Form
 Child Health Check-Up 221 Form and Claim Instructions — This form and instructions are available
at www.fdhc.state.fl.us/medicaid or by calling 1-800-289-7799
 Specialist as a PCP Request Form
 CMS-1500 (08-05) Claim Form
 UB-04-Claim Form
Precertification Forms
 Precertification Information Required for Hysterectomy
 Precertification Information Required for Gastroplasty
 Precertification Information Required for Tonsillectomy, Adenoidectomy, Adenotonsillectomy
Provider Grievances and Appeals Forms
 Provider Payment Dispute and Correspondence Submission
 Provider Medical Necessity Appeal Form
 Grievance Form
Medical Record Documentation Forms
 Adult Health Form
 Oral Lead Risk Form – English
 Oral Lead Risk Form – Spanish
 Incident Report Form
 Inpatient Medical Review Form
 Advance Directive – English
 Advance Directive – Spanish
 Durable Power of Attorney – English/Spanish
 Living Will – English/Spanish
 Site Review Form
Other Forms
 Florida Assisted Living Facility Form
 Authorization Request Form
 Pharmacy Prior Authorization Form
 Incident Report Form
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



Sterilization Consent Form
Hysterectomy Acknowledgement Form
Abortion Certificate Form
Provider Payment Dispute Form
Pharmacy Synagis Order Form
 Express Scripts Enrollment Form
Behavioral Health Forms
 Behavioral Health Outpatient Treatment Form
 Behavioral Health Outpatient Treatment Report C Form
 Request for Authorization – Psychological Testing Authorization Form
 Behavioral Health Neuropsychological Testing Form
Hysterectomy and Sterilization Forms
 Acknowledgement of Receipt of Hysterectomy Information
 Consent to Sterilization Form
Cost Containment Form
 Refund Notification Form
FL-PM-0024-14
- - 159 - -
FL-PM-0024-14 07.14

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