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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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

Policy Disclaimer >>

Policy Definitions >>

expand Anesthesia
expand Coding
Unlisted, Unspecified or Miscellaneous Codes
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 91: Repeat Clinical Diagnostic Laboratory Test
Modifier Usage
Reimbursement of Services with Obsolete Codes
Assistant at Surgery (Modifiers 80/AS)
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period
Reimbursement for Reduced and Discontinued Services
expand DME and Supplies
Durable Medical Equipment (Rent to Purchase)
expand Drugs
Drugs and Injectable Limits
expand Evaluation and Management
expand Facilities
Inpatient Facility Transfers
DRG Newborn Inpatient Stays
expand Prevention
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
expand Prosthetics and Orthotics
expand Radiology
Portable/Mobile/Handheld Radiology Services
expand Reimbursement Administration - General
Present on Admission Indicator for Health Care-Acquired Conditions
Reimbursement of Sanctioned and Opt-Out Providers
Site of Service Payment Differential – Professional
Reimbursement of Claims with Charge Discrepancies
Claims Submission – Required Information for Facilities
Code and Clinical Editing Guidelines
Eligible Billed Charges
Emergency Services: Non-Participating Providers and Facilities
Locum Tenens Physicians/Fee-for-Time Compensation
Reimbursement for Maximum Units Per Day
Medical Recalls
expand Surgery
Abortion (Termination of Pregnancy)
expand Transportation
Transportation Services: Ambulance and Nonemergent Transport