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 These policies may be superseded by state, federal or CMS requirements.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
Consultations
expand Facilities
Diagnosis-Related Group Inpatient Facility Transfers
expand Medicine
Multiple Procedure Payment Reduction
expand Prosthetics and Orthotics
expand Raidology
Multiple Radiology Payment Reduction
expand Reimbursement Administration - General
Claims Requiring Additional Documentation
Claims Submissions - 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
expand Surgery
Abortion (Termination of Pregnancy)
Hysterectomy
Multiple Delivery Services
Sterilization