Reimbursement Policies | Providers – Amerigroup

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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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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Policy Definitions >>

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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
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during the Postoperative Period
Modifier 57: Decision for Surgery
Modifier 63: Procedure Performed on Infants less than 4 kg
Modifier 76: Repeat Procedure by the Same Physician
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
Unlisted, Unspecified or Miscellaneous Codes
expand DME and Supplies
Facility Take-Home DME and Medical Supplies
expand Drugs
Facility Take-Home Drugs
expand Evaluation and Management
Preventive Medicine and Sick Visits on the Same Day
expand Facilities
DRG Newborn Inpatient Stays
Preadmission Services for Inpatient Stays
expand Laboratory
expand Prevention
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
expand Prosthetics and Orthotics
Prosthetic and Orthotic Devices
expand Radiology
Portable/Mobile/Handheld Radiology Services
expand Reimbursement Administration - General
Claims Submission – Required Information for Facilities
Claims Timely Filing
Corrected Claims
Duplicate or Subsequent Services on the Same Date of Service
Locum Tenens Physicians/Fee-for-Time Compensation
Nurse Practitioner and Physician Assistant Services
Reimbursement for Eligible Billed Charges
Reimbursement for Maximum Units Per Day
Reimbursement of Sanctioned and Opt-Out Providers
Scope of Practice​
expand Surgery
Abortion (Termination of Pregnancy)
Multiple Delivery Services
expand Transportation