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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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
Assistant at Surgery (Modifiers 80/81/82/AS)
Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
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
Split-Care Surgical Modifiers
expand Drugs
Drugs and Injectable Limits
expand Evaluation and Management
Preventive Medicine and Sick Visits on the Same Day
expand Facilities
Inpatient Readmissions
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: Participating and Nonparticipating
Documentation Standards for Episodes of Care
Emergency Services: Non-Participating Providers and Facilities
Other Provider Preventable Conditions (OPPC)
Reimbursement for Eligible Billed Charges
Reimbursement of Claims with Charge Discrepancies
Requirements for Documentation of Proof of Timely Filing
expand Surgery
Abortion (Termination of Pregnancy)
Robotic Assisted Surgery
expand Transportation
Transportation Services: Ambulance and Nonemergent Transport