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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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
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
Code and Clinical Editing Guidelines
Documentation Standards for Episodes of Care
Emergency Services: Nonparticipating Providers and Facilities
Medical Recalls
Present on Admission Indicator for Health Care-Acquired Conditions
Reimbursement for Items Under Warranty
Reimbursement of Claims with Charge Discrepancies
Requirements for Documentation of Proof of Timely Filing
Site of Service Payment Differential – Professional
expand Surgery
Global Surgical Package for Professional Providers
Maternity Services
Robotic Assisted Surgery
expand Transportation
Transportation Services: Ambulance and Nonemergent Transport