ProviderNews. The Many Faces of Substance Use Disorder Working With You to Achieve True Recovery. providers.amerigroup.com

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1 ProviderNews 2012 Issue 3 The Many Faces of Substance Use Disorder Working With You to Achieve True Recovery Substance Use Disorder (SUD) can affect anyone, no matter what age, economic status, gender or ethnicity. When it comes to SUD, our whole-person approach to care is vital to recovery, as SUD treatment goes beyond detoxification. SUD consumes a member s economic, social, health and psychological resources, says Dr. Gerald Busch, our associate medical director for Behavioral Health, who is board-certified in addiction psychiatry. Only when those resources are replenished do we consider the member fully recovered. While you treat the physical side of SUD, our case managers work with you to help these members get their lives back. How SUD Affects Our Membership Dr. Busch compares SUD to parasitism. Imagine our member, in addition to their other problems, having a parasite, he explains. The member doesn t really want to have it, yet it will stay there until the member receives specific treatment in this case, substance abuse treatment. This parasite is vigilant, and even with treatment, there is an ever-present risk of relapse. Our team is prepared to augment traditional treatment with ongoing recovery supports for all our members. Pregnant Moms Two Lives at Stake For our members already at high risk for issues like hypertension and preterm labor, SUD further threatens the chances of having healthy babies, hindering heart and lung development and increasing the risk of low birth weight. [The mother s] resources are being sapped, and the baby is being deprived of its usual abundant resources and exposed to toxins some of them habituating, says Dr. Busch. Our Taking Care of Baby and Me program pairs OB Case Managers (CMs) with high-risk members and their PCPs to improve health outcomes for both mom and baby through education, community support and necessary treatment for SUD, including detoxification. See Substance Use Disorder on Page 2 providers.amerigroup.com * In New Mexico, Amerigroup Community Care of New Mexico Inc.; in Louisiana, Amerigroup Louisiana Inc.; in the Medicaid Rural Service Areas of Texas, Amerigroup Insurance Company; in all other areas of Texas, Amerigroup Texas Inc.

2 Substance Use Disorder continued from Page 1 The Elderly Proper Use or Abuse? Just like parasitism, a member with SUD is often unaware of [his or her] affliction and will even say nothing is wrong, says Dr. Busch. This is common with our elderly members. Some get confused by their complex treatment plans or medication requirements. Others are depressed or lonely and intentionally overuse. Many are just too proud to ask for help. Through consistent outreach and one-on-one contact, our CMs and PCPs work together to ensure elderly members use their medicines properly. Children Recognizing Early Signs All illnesses in children and teens are difficult, but to see a teen s development disrupted by this process is particularly difficult, says Dr. Busch. Normally, a teen is working on issues related to independence and identity. These processes are disrupted by this parasite, and development is delayed. Early detection is key in combating SUD. In promoting age-appropriate preventive health services, or Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, we offer you screening tools to look for warning signs of depression, potentially damaging levels of sexual promiscuity, and other risky behaviors that often precede or accompany substance abuse. Families of Users Recovering Together Members with SUD aren t the only ones affected by the disease; the children and families of these members are also vulnerable to depression, illness and SUD themselves. Our CMs reach out to the families of members with SUD, connecting them with clinical support and community resources, such as Al-Anon and Alateen. Our CMs also work with treatment facilities where applicable to ensure the member s family is involved in his or her recovery and therapy when appropriate. In addition to case management, we also offer online resources and screening tools to help diagnose and treat patients with SUD. Log in to our provider website to find out more. September 2012 is National Recovery Month, a time to celebrate those in recovery; commend their providers and support systems; and promote prevention, diagnosis, and treatment of SUD and other behavioral health issues. As Recovery Month approaches, we thank you for working with us to help our members truly recover from SUD. Better Coordinate Referrals You already know our online provider directory is a key resource to help members find the right doctors, hospitals and specialists, but it s also a great tool for you. In August 2012, we launched a new online directory to make it easier for members to find you and for you to make referrals to other providers who are their best fits. The new directory updates nightly and gives detailed information about providers like gender, languages spoken, office hours and more. Our new directory can help you: n Find providers near mass transit routes in major cities using Google Transit n Compare doctors side by side n Create a personalized provider directory n See active providers and those who are about to join soon Need to update your contact information in our directory? Call Provider Services or contact your local Provider Relations representative. Member ID Cards Go Mobile Starting this summer, our members won t have to worry about forgetting their ID cards. With our new Amerigroup Mobile app, members can view their ID cards and or fax them to their doctors, pharmacies or hospitals right from their iphones, ipads, Android tablets or smartphones. The app is free from Apple itunes and the Android Market and will soon be available to members in most of our markets. We are one of the first managed care organizations to use this technology, and we re exploring even more capabilities like mobile provider directories and chat applications. For providers, this means: n Increased efficiency of your staff s interaction with patients n Fewer calls or online searches to get information from an ID card our member forgot to bring n Decreased wait times for receipt of ID card copies when you need them Amerigroup Plan Name Effective Date: Date of Birth: Subscriber #: Type of Coverage: Member Name: Primary Care Provider (PCP): PCP Telephone #: Copays: Office Visits: Emergency Room Visits: Pharmacy: Vision: For Prescription Drug Information: Para Información sobre Medicamentos Recetados: Amerigroup Member Services/Nurse HelpLine and Behavioral Health (24 hours a day, 7 days a week):

3 What Our Growth Really Means To us, growth means we ve done our job and we ve got an even bigger job to do. As states tax dollars shrink and more people need Medicaid, Medicare, CHIP or other types of government-funded assistance, our mission to provide real solutions for our members and our state partners becomes even more important. We recently expanded our operations in Texas to include Lubbock, El Paso and the state s Medicaid Rural Service Areas. We now serve people statewide in Georgia. In New York, we became HealthPlus Amerigroup to combine our strengths with those of the former Health Plus plan, resulting in access to care for more than 400,000 people in the state. This summer, we become fully operational in Louisiana and Washington. It s an exciting time for our company, and we re not done yet. We ve never worked as hard at adding new business as we have over the last few months, says Sarina Arcari, vice president of Amerigroup Project Management. So why the big push toward continued expansion? The economy, says Arcari. More [assistance] eligible people necessitate us having to grow. The states coffers are shrinking. Managed care is becoming a more viable option as [states] look to stretch their dollars and spend more effectively. The Impact of Health Care Reform Health care reform has everyone talking, says Arcari. It s now dinner conversation. The final decision on health care reform is big not only for Amerigroup, but for the industry as a whole. In terms of company growth, however, our expansion plans remain unchanged regardless of the reform decision; all other factors stay in place. The question, as Arcari put it, is do we grow or do we grow with turbo chargers? States are asking for more creativity for effective ways to keep levels of care appropriate while minimizing the potential for abuse of the managed care system. And, this happens to be our strong suit! Have you seen our Real Stories video series on our website? Nothing tells our stories better than close-up looks into how we change our members and providers lives for the better through innovation, creativity, and care with heart that actually saves states money. States are asking for more creativity for effective ways to keep levels of care appropriate while minimizing the potential for abuse of the managed care system. More Than Growth Evolution As proud as we are of our new opportunities, we aren t admiring our achievements in the rear view mirror. Not only are we increasing our footprint, we re expanding our products and services for members and providers. Here s a sampling of where we re headed and what we plan to offer: n Expansions through Southwest Virginia, the Healthy Kids program in Florida, statewide long-term services and supports in New Jersey, annual enrollment for Amerivantage (Medicare), and new programs in Kansas in 2013 n Additional opportunities for collaboration with providers through expansion of our patient-centered medical home programs in multiple states n More and better quality improvement and incentive programs for providers n Relaunches of our member and provider websites with new and improved functionality n And more Keep your eyes on our upcoming newsletter issues for the latest on new offerings and improved services.

4 PRSRT STD U.S. Postage PAID Amerigroup P.O. Box Virginia Beach, VA ProviderNews Questions? Medicaid providers call Medicare providers call PEC-ALL Making EPSDT Reporting Easier To make sure our members are getting appropriate Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, we annually measure our performance against the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) standards. Because the data we use to compile our reports comes from you, we want to help you deliver these services to members in your care and make it easier for you. We ve made a few changes to our EPSDT data collection process based on your feedback. Our redesigned EPSDT report will help you: n Easily identify members who are past due for EPSDT screenings; we ll also reach out to these members with reminders to schedule appointments n Track the reimbursements you receive for providing these invaluable services n Ensure you re paid quickly and accurately for the care you provide We listened to your feedback. Starting this year, you don t have to return a form to us anymore! Just make sure all your claims for these services are submitted as soon as possible. Thank you for helping us make sure our members get appropriate EPSDT care. Give your Provider Relations representative a call if you have questions about your EPSDT report. If your address, phone or fax numbers have changed, sign in at providers.amerigroup.com to update your contact information. You can also contact your local Provider Relations representative or call Provider Services at the numbers listed above. Check your member panel listings online they are updated daily so you get current eligibility information. Log in to our provider website and select PCP Member Listing from our tools menu to download by date range into a spreadsheet. Use our online Precertification Lookup tool to determine whether precertification or notification is required for services you give our members. It s easy and saves you time later by avoiding follow-up for denied claims. The material in this newsletter is intended for educational purposes only and does not constitute a recommendation or endorsement with respect to any company or product. Information contained herein related to treatment or provider practices is not a substitute for the judgment of the individual provider. The unique needs and medical condition of each patient must be taken into account prior to action on the information contained herein.

5 Texas News Look at Your Provider Manual as a Resource! Your provider manual includes information on: n Case Management and how to refer members n Clinical Practice Guidelines n Practitioner Rights n Member Rights and Responsibilities n Utilization Management n Covered Benefits and Services for members And much more! Many of the topics covered in the manual can be found on our website at providers.amerigroup.com/tx. In addition, you can always request paper copies of our materials by calling Provider Services. We welcome your suggestions! If you know of a way we could improve, please contact your Provider Relations representative. H H H H H H H H H H H H H H H H H H H H Complex Case Management Supports High-Risk Members Did you know that in addition to our disease management programs, we offer a complex case management program for our high-risk members? Using claims and utilization data, we can identify the diseases for which members are most at risk and to which they are most susceptible. Our case managers use evidence-based guidelines to coordinate care with members, their families, physicians, and other health-care providers. They work with everyone involved in the member s care to help implement a case management plan based on the member s needs. We provide education and support to our members and their families to help our members improve their health and quality of life. If you have a high-risk member you would like to refer to this program, please call us at Pharmacy Resources Are Online Providers can access the Amerigroup Formulary and Prior Authorization Form as well as the Preferred Drug List on our website at providers.amerigroup.com/tx. If you have questions regarding the formulary, call our Pharmacy department at

6 ? Utilization Management We model our Utilization Management (UM) program after the National Committee for Quality Assurance (NCQA) standards. If you have questions, would like additional information, or would like to speak to a medical director, please call us at for Medicaid or for Medicare and ask for the Health Care Management Services department. Appropriate practitioners are involved in the careful development, review, and approval of our UM decision-making criteria objective criteria based on medical evidence and applied according to the individual needs of the member and the local delivery system. If a medical necessity decision results in a denial decision, you can discuss it with an Amerigroup medical director. In keeping with NCQA standards, we notify our network practitioners and providers annually of our affirmative statement concerning UM decisions. UM decision-making is based only on appropriateness of care and service and existence of benefit coverage we do not reward practitioners or other individuals for issuing denials of coverage or care. H H H H H H H H H H H H H H H H H H H H Medical Management Issues A member of our clinical team can assist you with any questions you may have regarding a utilization decision or with any questions regarding the utilization management process in general. You can reach our Medical Management representatives at , Monday through Friday from 8:30 a.m. to 5:30 p.m. We Want Your Input Would you be interested in participating on a medical advisory committee or a credentialing subcommittee? These groups review our policies, procedures, and clinical practice guidelines. They also advise the health plan administration about the policies and operations affecting our network providers and members in order to improve services and clinical outcomes. If you would like to participate in either of these committees, please call Provider Services at TXPEC