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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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 or Miscellaneous Codes (aka: Dump 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)
expand DME and Supplies
Durable Medical Equipment (Rent to Purchase)
expand Drugs
Drugs and Injectable Limits
expand Evaluation and Management
Consultations
expand Facilities
Inpatient Readmissions
Preadmission Services for 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
Requirements for Documentation of Proof of Timely Filing
Scope of Practice
Claims Timely Filing
Claims Requiring Additional Documentation
Claims Submission – Required Information for Professional Providers
Duplicate or Subsequent Services on the Same Date of Service
Documentation Standards for Episodes of Care
Reimbursement for Items Under Warranty
Other Provider Preventable Conditions (OPPC)
Corrected Claims
expand Surgery
Sterlization
Hysterectomy
Abortion (Termination of Pregnancy)
expand Transportation