Medicare Reimbursement Policies | Providers – Amerigroup

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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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

Precertification/Prior Authorization Lookup >>

expand Anesthesia
expand Coding
Assistant at Surgery (Modifiers 80/81/82/AS)
Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
Modifier 22: Increased Procedural Service
Modifier 25
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
Modifier Usage
Split-Care Surgical Modifiers
Modifiers LT and RT: Left-Side/Right-Side Procedures
Multiple and Bilateral Surgery: Professional and Facility Reimbursement
expand DME and Supplies
Facility Take-Home DME and Medical Supplies
expand 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 Prosthetics and Orthotics
expand Radiology
Multiple Radiology Payment Reduction
expand Reimbursement Administration - General
Claims Requiring Additional Documentation
Code and Clinical Editing Guidelines
Documentation Standards for Episodes of Care
Emergency Services: Nonparticipating Providers and Facilities
Medical Recalls
Reimbursement for Items under Warranty
Claims with Charge Discrepancies
Requirements for Documentation of Proof of Timely Filing
Claims Submission — Required Information for Professional Providers
Preventable Adverse Events
expand Surgery
Abortion (Termination of Pregnancy)
Maternity Services
Robotic Assisted Surgery
expand Transportation