Reimbursement Policies | Providers – Amerigroup

GA & TX Medicaid Reimbursement Policies

We want to assist physicians, facilities and other providers in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member’s Amerigroup benefit plan. Keep in mind that determination of coverage under a member's benefit plan does not necessarily ensure reimbursement. These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements. Providers and facilities are required to use industry standard codes for claim submissions. Services should be billed with Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or Revenue codes. The billed code(s) should be fully supported in the medical record and/or office notes. Industry practices are constantly changing and Amerigroup reserves the right to review and revise its policies periodically.

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expand Anesthesia
expand Coding
Modifier 26 and TC: Professional and Technical Component
Diagnoses Used in Diagnosis-Related Groups Computation
DME Modifiers for New, Rented and Used Equipment
GA Modifier 77: Repeat Procedure by Another Physician
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Modifier 62: Co-Surgeons
Modifier 66: Surgical Teams
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period
Modifier Usage
Multiple and Bilateral Surgery: Professional and Facility Reimbursement
Reimbursement of Services with Obsolete Codes
TX Diagnoses Used in DRG Computation
TX Modifier 76: Repeat Procedure by the Same Physician
Unlisted, Unspecified or Miscellaneous Codes
expand DME and Supplies
Facility Take-Home DME and Medical Supplies
expand Drugs
expand Evaluation and Management
Consultations
expand Facilities
DRG Inpatient Facility Transfers
Inpatient Readmissions
expand Laboratory
Drug Screen Testing
expand Prevention
Vaccines for Children Program
expand Prosthetics and Orthotics
expand Radiology
Multiple Radiology Payment Reduction
expand Reimbursement Administration - General
Claims Requiring Additional Documentation
Claims Submission – Required Information for Professional Providers
Corrected Claims
Duplicate or Subsequent Services on the Same Date of Service
GA Claims Timely Filing
Locum Tenens Physicians/Fee-for-Time Compensation
Nurse Practitioner and Physician Assistant Services
Reimbursement for Eligible Billed Charges
Reimbursement of Claims with Charge Discrepancies
Requirements for Documentation of Proof of Timely Filing
Site of Service Payment Differential – Professional
TX Claims with Charge Discrepancies
expand Surgery
Abortion (Termination of Pregnancy)
Hysterectomy
Multiple Delivery Services
Sterilization
expand Transportation
Transportation Services: Ambulance and Nonemergent Transport