Texas MMP Reimbursement Policies | Providers – Amerigroup

TX MMP 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 STAR+PLUS MMP benefits. 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 These policies may be superseded by state, federal or CMS requirements. Providers and facilities are required to use industry standard codes for claim submissions. Services should be billed with CPT codes, 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 STAR+PLUS MMP reserves the right to review and revise its policies periodically.

Policy Disclaimer >>

Policy Definitions >>

expand Anesthesia
expand Coding
Assistant at Surgery (Modifier 80/81/82/AS)
Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
Modifier 22: Increased Procedural Service
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Modifier 57: Decision for Surgery
Modifier 66: Surgical Teams
Modifier 77: Repeat Procedure by Another Physician
Modifier 91: Repeat Clinical Diagnostic Laboratory Test
Modifiers LT and RT: Left Side/Right Side Procedures
Reimbursement for Reduced and Discontinued Services
Split-Care Surgical Modifiers
expand DME and Supplies
Durable Medical Equipment (Rent to Purchase)
expand Drugs
Drugs and Injectable Limits
expand Evaluation and Management
expand Facilities
DRG Inpatient Facility Transfers
Preadmission Services for Inpatient Stays
expand Laboratory
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
Corrected Claims
Duplicate or Subsequent Services on the Same Date of Service
Emergency Services: Nonparticipating Providers and Facilities
Medical Recalls
Present on Admission Indicator for Health Care-Acquired Conditions
Reimbursement for Maximum Units Per Day
Reimbursement of Sanctioned and Opt-Out Providers
Scope of Practice
expand Surgery
Abortion (Termination of Pregnancy)
Multiple Delivery Services
expand Transportation