PARTICIPATING PROVIDER

1. PARTICIPATING PROVIDER ORIENTATION

2. AmeriHealth VIP Care and AmeriHealth VIP Select This training program is designed to familiarize Providers with AmeriHealth VIP Care and AmeriHealth VIP Select. At the conclusion of the training, providers will be familiar with the AmeriHealth VIP Care and AmeriHealth VIP Select’s Model of Care, the role of the Provider in the Model of Care and the AmeriHealth VIP Care and AmeriHealth VIP Select’s resources available to the Provider and Member for both AmeriHealth VIP Care and AmeriHealth VIP Select. • AmeriHealth VIP Care is a Medicare Advantage Dual Eligible Special Needs Health Maintenance Organization. (D-SNP/HMO) • AmeriHealth VIP Select is a Medicare Advantage Prescription Drug Health Maintenance Organization. (MAPD/HMO)

3. AmeriHealth VIP Care and AmeriHealth VIP Select are members of the AmeriHealth Caritas Family of Companies - the industry leader in managing medically complex members. We are expanding our membership to continue our vision and mission to provide healthcare services to the underserved. AmeriHealth VIP Care enables us to offer our existing and eligible chronically ill Medicaid members a seamless transition to a Medicare Advantage Special Needs Plan. AmeriHealth VIP Select enables us to offer this same level of service to the traditional Medicare member. Who We Are

4. Why AmeriHealth VIP Care and AmeriHealth VIP Select? • As a member of AmeriHealth Caritas, AmeriHealth VIP Care and AmeriHealth VIP Select are uniquely qualified to provide these populations with the coordinated care they deserve. AmeriHealth Caritas – care is the heart of our work: • Nearly 5 Million Covered Lives • 3,000+ Employees • NCQA-Accredited plans

5. Why AmeriHealth VIP Care and AmeriHealth VIP Select? AmeriHealth VIP Care and AmeriHealth VIP Select are well equipped to provide high-level customer service to members and providers. AmeriHealth’s corporate systems and centers currently: • Handle more than 2.25 million member and provider calls annually in our 24/7 call centers. • Process an average of 2.1 million claims each month. • Receive more than 87 percent of provider claims electronically with automatic adjudication rates of more than 81 percent.

6. Why AmeriHealth VIP Care and AmeriHealth VIP Select? The success of AmeriHealth Caritas’ mission-driven programs is evidenced by the national recognition and awards received. All established AmeriHealth Caritas Medicaid plans currently rank in the top 19th percentile of Medicaid health plans: AmeriHealth Caritas Pennsylvania (Harrisburg Area) Excellent Accreditation Keystone First (Philadelphia Area) Excellent Accreditation MDwise Hoosier Alliance (Indiana) Excellent Accreditation Select Health (South Carolina) Excellent Accreditation Based upon NCQA Health Insurance Plan Rankings 2012-2013, issued September 20, 2012.

7. AmeriHealth VIP Care and AmeriHealth District of Columbia • AmeriHealth Caritas is focused on extending the services that we provide under the AmeriHealth District of Columbia Medicaid Plan to members who have become eligible for Medicare due to age or disability.

8. We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. Mission Statement

10. AmeriHealth VIP Care (D-SNP) Plan Overview • AmeriHealth VIP Care Overview • AmeriHealth VIP Care is contracted to provide Medicare Hospital (Part A), Medical (Part B) services, and Prescription Drug Coverage (Part D) services in the District of Columbia. • Members must live in one of the eight wards in the District of Columbia to join AmeriHealth VIP Care. • AmeriHealth VIP Care Enrollment • Will accept only those beneficiaries with dual Medicaid/Medicare eligibility. • Members can enroll or change plans at any time. • Members can enroll by calling member services at 888-996-0799.

11. AmeriHealth VIP Care (D-SNP) – Dual Eligible Special Needs Plan • Our Members • Reside in one of the eight wards in the District of Columbia. • Have or will soon have Medicare Parts A and B. • Do not have end-stage renal disease. • Receive medical assistance benefits through the District of Columbia Medicaid fee-for-service system.

12. Summary of AmeriHealth VIP Care’s Benefit Package Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Hospice – Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Kidney Disease and Condition Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network Catastrophic Prescriptions Outpatient Prescription Drugs Retail Pharmacy Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care

13. AmeriHealth VIP Care (D-SNP) Supplemental Benefits – Dental • DENTAL SERVICES • Preventative Dental • Oral Exams – 1 every 6 months • Cleaning – 1 every 6 months • Fluoride Treatment – 1 every 6 months • Dental x-rays – 1 every year • Comprehensive Dental • Non-routine services including fillings, simple extractions, minor restorations, dentures and denture repair • $500 every two years

14. AmeriHealth VIP Care (D-SNP) Supplemental Benefits –Vision • VISION SERVICES • Up to one supplemental routine Eye Exam every year • Up to one pair of eyeglasses or contact lenses every two years • $150 coverage limit for supplemental eyewear every two years

15. AmeriHealth VIP Care (D-SNP) Supplemental Benefits –Hearing • HEARING SERVICES • Up to one supplemental routine Hearing Exam every year • Up to one fitting evaluation for a hearing aid every three years • Up to $1,000 coverage for hearing aids every three years

16. Supplemental Benefits –Non-Emergency Transportation • Transportation Services • Twenty-four (24) one-way trips per year to a AmeriHealth VIP Care approved location • Car, shuttle, van services, including non-emergent transportation to doctor visits, preventive services, pharmacies and fitness center • Authorization and scheduling rules apply

17. Supplemental Benefits – Over the Counter Items • Over the Counter (OTC) • Typically includes medicines or products that alleviate or treat injuries or illness • OTC products are shipped directly to the member • No statement from a medical provider required or documentation of a diagnosis to use the benefit • Up to $50 every three months • No roll-over quarter to quarter

18. Supplemental Benefits– Health and Wellness • Gym Memberships • Available to AmeriHealth VIP Care members • Members may choose which gym they would like to belong to from gyms such as the YMCA and other local gyms • Members may call member services at (888) 996-0799 to arrange for membership

19. Supplemental Benefits– 24/7/365 Nurse Line • If members are unable to reach their PCP’s office, registered nurses are available 24/7/365 days to assist members through the Nurse Toll-Free Call Line. • AmeriHealth VIP Care Nurse Call Line: (855) 327-5050

21. AmeriHealth VIP Select (MA-PD) Plan Overview • AmeriHealth VIP Select Overview • AmeriHealth VIP Select is contracted to provide Medicare Hospital (Part A), Medical (Part B) services, and Prescription Drug Coverage (Part D) services in the District of Columbia. • AmeriHealth VIP Select Enrollment • Beneficiaries must have Part A and B. • Members must live in one if the eight wards in the District of Columbia to join AmeriHealth VIP Select. • Members can enroll by calling member services at member services (888)-996-0899.

22. AmeriHealth VIP Select– Medicare Advantage Prescription Drug Plan • Our Members • Reside in one of the eight wards in the District of Columbia. • Have or will soon have Medicare Parts A and B. • Do not have end-stage renal disease.

23. Summary of AmeriHealth VIP Select’s Benefit Package Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Hospice – Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Kidney Disease and Condition Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network Catastrophic Prescriptions Outpatient Prescription Drugs Retail Pharmacy Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care

24. AmeriHealth VIP Select Supplemental Benefits – Dental • DENTAL SERVICES • Preventative Dental • Oral Exams – 1 every 6 months • Cleaning – 1 every 6 months • Fluoride Treatment – 1 every 6 months • Dental x-rays – 1 every year • $30 copay for up to 1 supplemental oral exam(s) every six months

25. AmeriHealth VIP Select Supplemental Benefits –Vision • VISION SERVICES • $30 copay for up to one supplemental routine Eye Exam every year • $100 towards glasses or contacts every two years

26. AmeriHealth VIP Select Supplemental Benefits –Hearing • HEARING SERVICES • $0 copay for Medicare-covered diagnostic hearing exams • Routine services are not a covered benefit

27. Supplemental Benefits (continued) – 24/7/365 Nurse Line • If members are unable to reach their PCP’s office, registered nurses are available 24/7/365 days to assist members through the Nurse Toll-Free Call Line. • AmeriHealth VIP Select Nurse Call Line: (855) 327-5050

28. Member Eligibility

29. Member Rights and Responsibilities • Member Rights and Responsibilities • Federal law requires that health care providers and facilities recognize member rights. Members have the right to request and receive from their health care provider, a complete copy of the Patient’s Bill of Rights and Responsibilities. • Providers may refer to the Provider Manual for a detailed listing of the Member’s Rights and Responsibilities.

30. Member Welcome Packet AmeriHealth VIP Care and AmeriHealth VIP Select Member welcome packets includes: • Cover (Welcome) Letter • Provider & Pharmacy Directory • The AmeriHealth VIP Care and AmeriHealth VIP Select’s Formulary • Evidence Of Coverage (EOC) document • Health Risk Assessment (HRA) and return envelope • Multi-Language Insert • Notice of Privacy Practices • Member grievance process Member materials, including a summary of benefits compared to Original Medicare and complete evidence of coverage information, are accessible via our website at www.amerihealthvipdc.com or AmeriHealth VIP Care member services at 888-996-0799 or AmeriHealth VIP Select member services at 888-996-0899.

31. Member PCP Selection • Members may select a new PCP at any point in time by calling AmeriHealth VIP Care member services at 888-996-0799 or AmeriHealth VIP Select member services at 888-996-0899. • An updated card will be sent to the member each time there is a change in eligibility or PCP. • Because a member may present with a card with old information, AmeriHealth VIP Care and AmeriHealth VIP Select encourages providers to validate member eligibility at each visit.

32. Member Eligibility • Providers are responsible for verification of member’s eligibility status prior to the delivery of services. • Providers may verify eligibility by: • Utilizing the monthly member panel roster • NaviNet • Provider Services for AmeriHealth VIP Care 888-996-0799 • Provider Services for AmeriHealth VIP Select 888-996-0899

33. NaviNet • What is NaviNet? • A FREE web-based solution for providers and health plans to share critical administrative, financial and clinical data. • America’s largest real-time healthcare communications network, securely linking providers nationwide through a single website. • Provider portal address: • https://connect.NaviNet.net • Informational website • www.NaviNet.net • NaviNet Web Portal: www.navinet.net Phone: (888) 482-8057 • Must be accessed via Internet Explorer v. 7.0 or above • Older versions of IE may not work appropriately • Not accessible via Firefox, Safari or Google Chrome

34. NaviNet (continued) • NaviNet Functions: View Member Eligibility Member Rosters View Third Party Liability Information (TPL) Claims Status & Updates Prior Authorization HEDIS Performance On-Line Remittance Advice Care Plans Clinical Summary Referrals Care Gaps

35. Potential NaviNet Issues • Providers who do not show AmeriHealth VIP Care and AmeriHealth VIP Select as an option on the Plan Central page should contact NaviNet to request access. This can occur in two ways. • Click on My Account at the top of the NaviNet page • Support Cases will be located on the left side of the screen • Providers may Open a Case or View a Case here. • Send an email to NaviNet Support at NaviNet@NaviNet.net • All Support Cases or requests submitted via email should include: • Tax identification Number (TIN) • NaviNet user contact name and phone number • Group and provider NPI’s to be added or terminated • Transaction access request (Eligibility, Referrals, Prior Authorization Management, etc.)

36. Accessing Member Eligibility via NaviNet • On the AmeriHealth VIP Care and AmeriHealth VIP Select landing page, NaviNet will provide alerts if there are issues with search functions or availability. • Providers may also call Provider Services for AmeriHealth VIP Care 888-996-0799 or Provider Services for AmeriHealth VIP Select 888-996-0899 to verify eligibility.

37. Member Eligibility via NaviNet

38. Monthly Panel Roster • Provider panel rosters will be available on a monthly basis to provide PCP offices with a listing of AmeriHealth VIP Care and AmeriHealth VIP Select members who have chosen their practice. Member information on the panel roster will include: • The member’s name, address and telephone number • Date of birth and age • Gender • Effective date with AmeriHealth VIP Care or AmeriHealth Select Plan • AmeriHealth VIP Care and AmeriHealth VIP Select Medicare Identification number • State Medicaid Identification Number (if applicable) • Primary Language spoken • Medicare Plan Type (D-SNP-HMO or MAPD HMO)

39. AmeriHealth VIP Care Member Panel Roster

40. AmeriHealth VIP Care and AmeriHealth VIP Select– A Medicare Replacement • For AmeriHealth VIP Care and AmeriHealth VIP Select members, AmeriHealth VIP Care or AmeriHealth VIP Select should be entered into the provider’s billing system in the place of Medicare Fee for Service. • If a provider has Medicare or another Medicare Advantage plan loaded in their patient management system for an AmeriHealth VIP Care or AmeriHealth VIP Select member, AmeriHealth VIP Care or AmeriHealth VIP Select will replace this plan. • The AmeriHealth VIP Care member will have District of Columbia Medicaid secondary to AmeriHealth VIP Care, even if the member previously enrolled in AmeriHealth District of Columbia.

41. Provider Participation

42. AmeriHealth VIP Care and AmeriHealth VIP Select Medicare Provider Eligibility • Health care providers are selected to participate in the AmeriHealth VIP Care and AmeriHealth VIP Select Network based on an assessment and determination of the network's needs. • Providers must be enrolled with the Medicare program in order to be credentialed with AmeriHealth VIP Care and AmeriHealth VIP Select.

43. Provider Credentialing • AmeriHealth VIP Care and AmeriHealth VIP Select is responsible for the credentialing and re-credentialing of its provider network. • Hospital-based physicians are not required to be independently credentialed if those providers serve AmeriHealth VIP Care and AmeriHealth VIP Select members only through the hospital. • All providers credentialed by AmeriHealth VIP Care and AmeriHealth VIP Select must also be enrolled with the Medicare program and, as such, must agree to comply with all pertinent Medicare regulations.

44. AmeriHealth VIP Care and AmeriHealth VIP Select Credentialing • AmeriHealth VIP Care and AmeriHealth VIP Select credentialing/re-credentialing criteria and standards are consistent with the Centers for Medicare and Medicaid Services’ specific requirements and National Committee for Quality Assurance (NCQA) standards. Practitioners and facility/organizational providers are re-credentialed every three years. • AmeriHealth VIP Care and AmeriHealth VIP Select works with the Council for Affordable Quality Healthcare (CAQH) to offer providers a Universal Provider Data source that simplifies and streamlines the data collection process for credentialing and re-credentialing. • Through CAQH, providers submit credentialing information to a single repository, via a secure Internet site, to fulfill the credentialing requirements of all health plans that participate with CAQH. AmeriHealth VIP Care and AmeriHealth VIP Select’s goal is to have all providers enrolled with CAQH.

45. Medical Records Requirements • Providers are required to maintain medical records in accordance with the Provider Manual. • Requirements include, but are not limited to: • Elements in the medical record are organized in a consistent manner, and the records are kept secure; • Patient’s name or identification number is on each page of record; • All entries are dated and legible; • All entries are initialed or signed by the author; • Personal and biographical data are included in the record; • Current and past medical history and age-appropriate physical exam are documented and include serious accidents, operations and illnesses; • Allergies and adverse reactions are prominently listed or noted as “none” or No Known Allergies “NKA”; • Information regarding personal habits such as smoking and history of alcohol use and substance abuse (or lack thereof) is recorded when pertinent to proposed care and/or risk screening.

46. Access to Care Access to Care • AmeriHealth VIP Care and AmeriHealth VIP Select PCPs, specialists and behavioral health providers must meet standard guidelines as outlined in the Provider Manual to help ensure that AmeriHealth VIP Care and AmeriHealth VIP Select members have access to care. • AmeriHealth VIP Care and AmeriHealth VIP Select’s Access Standards: • Assure members’ accessibility to health care services • Establish mechanisms for measuring compliance with existing standards • Identify opportunities for the implementation of interventions for improving accessibility to health care services for members • Office Accessibility • The following areas are monitored by AmeriHealth VIP Care and AmeriHealth VIP Select to ensure physician access standards are continually met: • PCP office hours must be clearly posted and reviewed with members during the initial office visit.     • The PCP is required to arrange for coverage of primary care services during absences due to vacation, illness or other situations that render the PCP unable to provide services.  A Medicare-eligible PCP must provide the coverage to AmeriHealth VIP Care and AmeriHealth VIP Select members.

47. Provider Appointment Scheduling • Appointment Scheduling • AmeriHealth VIP Care and AmeriHealth VIP Select monitors access standards on an annual basis.  Specialists who are serving in the PCP role (i.e. Internal Medicine, Family Practice, Pediatrics, or OB/GYN) are subject to the PCP Access Standards. • Timely Access Standards for appointment availability for Primary Care Physicians (PCPs), Specialists and Behavioral Health providers are outlined on slide 48. • Missed Appointment Tracking • If a member misses an appointment with a provider, the provider should document the missed appointment in the member’s medical record.  • Providers should make at least three attempts to contact the member and determine the reason. The medical record should reflect any reasons for delays in performing the examination. • Medical record should include any refusals by the member.

48. Physician Office Standards Primary Care and Behavioral Health Provider Access Standards: Emergent Care 24/7 Request Immediately or referred to ER Urgent Care Within two (2) calendar days of request Routine Care Within 14 calendar days of request Specialty Care Provider Access Standards: Routine Care Within 30 business days of request

49. Access to Care • Access to After-Hours Care • Members should have access to quality, comprehensive health care services 24 hours a day, 7 days a week. • PCPs and behavioral health providers must have either an answering machine or an answering service for members during after-hours for non-emergent issues. • The answering service must forward calls to the PCP or on-call provider, or instruct the member that the provider will contact the member within 30 minutes. • When an answering machine is used after hours, the answering machine must provide the member with a process for reaching a provider after hours. The after-hours coverage must be accessible using the medical office’s daytime telephone number. • For emergent issues, both the answering service and answering machine must direct the member to call 911 or go to the nearest emergency room. • AmeriHealth VIP Care and AmeriHealth VIP Select monitor access to after-hours care on an annual basis by conducting a survey of PCP offices after normal business hours.

50. AmeriHealth VIP Referrals