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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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

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 Reimbursement Policies

collapse Anesthesia
     expand Professional Anesthesia Services
Effective Date:6/18/2012
Policy:
Amerigroup allows reimbursement of anesthesia services rendered by professional providers for covered members unless provider, state, federal, or CMS contracts or requirements indicate otherwise. Reimbursement is based upon:
  • The reimbursement formula for the allowance and time increments in accordance with CMS
  • Proper use of applicable modifiers
Providers must report actual anesthesia time in minutes on the claim and may also include start and stop times. Start and stop times must be documented in the member’s medical record. Anesthesia time starts with the preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance. In the event the minutes reported on the claim do not match the minutes documented by the start and stop time, the start and stop time will be used to calculate the anesthesia time. The reimbursement formula for anesthesia allowance is based on CMS guidelines, unless otherwise noted in the exemption section.

Anesthesia Modifiers

Anesthesia modifiers are appended to the applicable procedure code to indicate the specific anesthesia service or who performed the service. Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field to receive appropriate reimbursement. Additional or reduced payment for modifiers is based on state requirements, as applicable. If there is no state requirement, Amerigroup will default to the following CMS guidelines. Claims submitted for anesthesiology services without the appropriate modifier will be denied.
  • Modifier AA: anesthesiology service performed personally by an anesthesiologist—reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated rate
  • Modifier AD: medical supervision by a physician; more than four concurrent anesthesia procedures—reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated rate for up to three base units for anesthesiologists who supervise three or more concurrent or overlapping procedures
  • Modifier QK: medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals—reimbursement is based on 50 percent of the applicable fee schedule or contracted/negotiated amount
  • Modifier QX: Certified Registered Nurse Anesthetist (CRNA) service with medical direction by a physician—reimbursement is based on 50 percent of the applicable fee schedule or contracted/negotiated amount
  • Modifier QY: anesthesiologist medically directs one CRNA—reimbursement is based on 50 percent of the applicable fee schedule or contracted/negotiated amount
  • Modifier QZ: CRNA service without medical direction by a physician—reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated amount
  • Modifier 23: denotes a procedure that must be done under general anesthesia due to unusual circumstances although normally done under local or no anesthesia—reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated rate of the procedure. Modifier 23 does not increase or decrease reimbursement; it substantiates billing anesthesia associated with the procedure in cases where anesthesia is not usually appropriate.
  • Modifier 47: denotes regional or general anesthesia services provided by the surgeon performing the medical procedure. Amerigroup does not allow reimbursement of anesthesia services by the provider performing the medical procedure (other than obstetrical—see Obstetrical Anesthesia section of this policy); therefore, it is not appropriate to bill Modifier 47.

Multiple Anesthesia Procedures

Amerigroup allows reimbursement for professional anesthesia services during multiple procedures. Reimbursement is based on the anesthesia procedure with the highest base unit value and the overall time of all anesthesia procedures.

Obstetrical Anesthesia

Amerigroup allows reimbursement for professional neuraxial epidural anesthesia services provided in conjunction with labor and delivery for up to 300 minutes by either the delivering physician or a qualified provider other than the delivering physician based on the time the provider is physically present with the member. Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes. Reimbursement is based on one of the following:
  • For the delivering physician—based on a flat rate or fee schedule using the surgical CPT pain management codes for epidural analgesia
  • For a qualified provider other than the delivering physician—based on:
    • The allowance calculation
    • Inclusive of catheter insertion and anesthesia administration

Services Provided in Conjunction with Anesthesia

Amerigroup allows separate reimbursement for the following services provided in conjunction with the anesthesia procedure or as a separate service. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate with no reporting of time:
  • Swan-Ganz catheter insertion
  • Central venous pressure line insertion
  • Intra-arterial lines
  • Emergency intubation (must be provided in conjunction with the anesthesia procedure to be considered for reimbursement)
  • Critical care visits
  • Transesophageal echocardiography
Nonreimbursable

Amerigroup does not reimburse for:

  • Use of patient status modifiers or qualifying circumstances codes denoting additional complexity levels
  • Anesthesia consultations on the same date as surgery or the day priorto surgery if part of the pre-operative assessment
  • Anesthesia services performed for noncovered procedures, including services considered not medically necessary, experimental and/or investigational
  • Anesthesia services by the provider performing the basic procedure, except for a delivering physician providing continuous epidural analgesia
  • Local anesthesia considered incidental to the surgical procedure
Exemptions:
  • Amerigroup Washington Inc. allows reimbursement of anesthesia for labor and delivery time for a maximum of 360 minutes in compliance with the Washington Health Care Authority (HCA).
  • The following states use a reimbursement formula for anesthesia allowance based upon American Society of Anesthesiologist guidelines:
    • Georgia
    • New Jersey
    • Ohio
  • Amerigroup Virginia, Inc. uses a reimbursement formula for anesthesia allowance based upon Department of Medical Assistance Services guidelines.
  • Amerigroup Florida Inc., in compliance with the Agency for Health Care Administration Medicaid Services Coverage and Limitations handbook:
    • Rounds time units down to the nearest 15-minute increment
    • Uses the following reimbursement formula for allowance calculation:anesthesia base rate plus (time divided by 15 multiplied by the conversion factor) [NOTE: The Anesthesia Base Rate is listed on the Florida Physician Anesthesia Services Fee Schedule]
    • Only recognizes Modifiers QK, QS and 22 as valid modifiers for anesthesia services; Florida anesthesia claims submitted with modifiers other than QK, QS and 22 will be denied. Modifier 22 is billed when the member returns to the operating room on the same day with the same anesthesia provider. The second service is billed with Modifier 22 and a report documenting a return trip to the operating room must be submitted with the claim.
    • Allows reimbursement to medically directed CRNAs based on 80 percent and to the physician billing Modifier QK based on 20 percent of the applicable fee schedule or contracted/negotiated rate
  • Amerigroup Georgia Managed Care Company, Inc.:
    • Rounds time units to the nearest whole number
    • Allows use of the following patient status modifiers
    • Modifier P3: a patient with severe systemic disease — allows additional reimbursement of one time unit
    • Modifier P4: a patient with severe systemic disease that is a constant threat to life — allows additional reimbursement of two time units
    • Modifier P5: a moribund patient who is not expected to survive without the operation — allows additional reimbursement of three time units
  • Amerigroup Maryland, Inc. does not allow reimbursement for the use of Modifier AD. Maryland claims submitted with Modifier AD will be denied.
  • Amerigroup New York, LLC allows reimbursement for regional or general anesthesia services provided by the surgeon performing the medical procedure and the use of Modifier 47—this does not apply to local anesthesia.
  • Amerigroup Texas, Inc. allows reimbursement of CRNAs at 92 percent of the rate reimbursed to a physician anesthesiologist for the same service.
Policy History:
  • Review approved and effective 06/18/12: Washington exemption added
  •  Review approved 02/27/12 and effective 10/01/12: Updated start and stop time language due to change in HIPAA 5010 instructions
  • Review approved July 18, 2011, and effective November 5, 2009: Background section/policy template updated; Start/stop time language added; Texas, Georgia, Virginia, New Jersey and Ohio exemptions added
  • Review approved July 8, 2009, and effective November 5, 2009: Policy combined with Anesthesia Modifiers #06-165; reimbursement formula for anesthesia calculation clarified; anesthesia modifier information added; nonreimbursement of patient status modifiers clarified; medical criteria removed; dental anesthesia benefit information removed; SC medical scope of practice exemption removed; Texas and Tennessee benefit exemptions removed; Florida unit rounding clarified; Georgia unit rounding and patient status modifier exemption added; obstetrical epidural anesthesia limit added; Background section/policy template updated; references to Modifier Usage #06-066 and Modifier 23 Unusual Anesthesia #07-021 policies added
  • Update due to regulatory directive (Committee Approval is not required in accordance with Reimbursement Policy Program Guidelines, policy #05-017):
    • October 15, 2008, to add SC exemption
  • Initial committee approval May 30, 2007, and effective July 1, 2007
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS
  • State Medicaid
  • Amerigroup state contracts
  • American Society of Anesthesiologists
  • Ingenix Learning: Understanding Modifiers, 20010 edition
Definitions:
  • Anesthesia: refers to the drugs or substances that cause a loss of consciousness or sensitivity to pain.
  • Base unit: the relative value unit associated with each anesthesia procedure code as assigned by CMS
  • Time unit: an increment of fifteen (15) minutes where each 15-minute increment constitutes one (1) time unit
  • Conversion factor is a geographic-specific amount that varies by the locality where the anesthesia is administered
  • Reimbursement Policy Definitions
Related Policies:
  • Modifier Usage
  • Modifier 23: Unusual Anesthesia
Related Material:
  • Obstetrical Services
collapse Coding
     expand Diagnoses Used in Diagnosis-Related Groups Computation
Effective Date:4/15/2013
Policy:
Amerigroup ensures the diagnosis and procedure codes that generate the Diagnosis Related Groups (DRG) — and consequently, the hospital invoice — are accurate, valid and sequenced in accordance with national coding standards and specified guidelines unless provider, state, federal, or CMS contracts or requirements indicate otherwise.
 
Amerigroup performs DRG audits to determine that the diagnostic and procedural information that led to the DRG assignment is substantiated by the medical record. The audits utilize coding criteria to limit the billed diagnosis used in DRG computation to those that are relevant to the patient’s care; impact the patient’s outcome, treatment, intensity of service or length of stay; and are supported by documentation within the medical record.
 
Amerigroup routinely monitors DRG billing patterns to ensure that hospitals perform fair and equitable coding and utilization.
Exemptions:
There are no exemptions to this policy.
Policy History:
  • Initial committee approval 07/16/12 and effective 04/15/13
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS
  • State Medicaid
  • Amerigroup state contracts
  • The American Medical Association
Definitions:
DRGs are a patient classification method which provides a means of relating the type of patients a hospital treats to the costs incurred by the hospital.
 
General Reimbursement Policy Definitions
Related Policies:
  • Present on Admission Hospital Acquired Conditions
  • Documentation Standards for an Episode of Care
Related Material:
None
     expand Modifier 22: Increased Procedural Service
Effective Date:10/12/2012
Policy:
Amerigroup allows reimbursement for procedure codes appended with Modifier 22 when the procedure or service provided is greater than what is usually required for the listed procedure code, unless provider, state, federal, or CMS contracts or requirements indicate otherwise.

Amerigroup performs prepayment review to support the use of Modifier 22. If medical review of the documentation submitted with the claim supports Modifier 22, reimbursement is based on 120 percent of the fee schedule or contracted/negotiated rate for the procedure appended with Modifier 22.

If the documentation does not support the use of Modifier 22 or there is no documentation submitted with the claim, reimbursement will not exceed 100 percent of the fee schedule or contracted/negotiated rate of the procedure. Modifier 22 is appropriate to use only with surgery, radiology, pathology, laboratory, and medicine procedure codes with a global period of 0, 10, or 90 days.

Nonreimbursable

Amerigroup does not allow reimbursement for use of Modifier 22:

  • With an inappropriate procedure code
  • With procedures that do not have a global period (i.e. add-on codes)
  • To indicate a procedure performed by a specialist
Amerigroup does not allow additional reimbursement for anesthesia services billed with Modifier 22.

Exemptions:
  • Amerigroup Louisiana, Inc. allows reimbursement of Modifier 22 at 125 percent of the fee schedule or contracted/negotiated rate in compliance with the Louisiana Department of Health and Hospitals (Effective February 1, 2012).
  • Amerigroup Nevada, Inc. allows reimbursement of Modifier 22 at 125 percent of the fee schedule or contracted/negotiated rate in compliance with the Nevada Department of Health and Human Services.
  • Amerigroup Washington, Inc., in compliance with Washington State Department of Social and Health Services and Health Care Authority, does not allow additional reimbursement of Modifier 22 (for informational purposes only).
  • Amerigroup Kansas, Inc., in compliance with Kansas Medical Assistance Program, allows reimbursement for anesthesia services billed with Modifier 22.
Policy History:
  • Policy approved 08/27/12: Washington and Kansas exemptions added
  • Policy approved March 12, 2012, and effective October 1, 2012, Louisiana exemption added
  • Review approved September 12, 2011, and effective November 10 2009: language clarified for ease of understanding; Background and Definitions sections, policy template updated
  • Review approved July 13, 2009, and effective November 10, 2009: Denial for no documentation removed; modifier definition updated; Background section updated
  • Initial committee approval June 6, 2007, and effective October 4, 2007
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS
  • State Medicaid
  • Amerigroup state contracts
  • American Medical Association: Coding with Modifiers, Third Edition
  • Ingenix Learning: Understanding Modifiers, 2011 edition
Definitions:
Related Policies:
Modifier Usage
 
Related Material:
None
 
     expand Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during the Postoperative Period
Effective Date:5/4/2006
Policy:

Amerigroup allows limited reimbursement for physician claims billed with Modifier 24, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated rate for the Evaluation and Management (E&M) service performed during the postoperative period of the original procedure if the following criteria are met:

  • The appropriate level of E&M service is billed and appended with Modifier 24
  • A diagnosis code unrelated to the original procedure is indicated for the E&M service
  • The reason for the E&M service is clearly documented in the member’s medical record

Failure to use Modifier 24 correctly may result in denial of the E&M service.

Exemptions:
There are no exemptions to this policy.
 
Policy History:
  • Review approved 04/23/12: Policy template updated
  • Review approved 06/06/11: Background section/policy template updated.
  • Review approved 06/21/10: Definitions and Background sections updated; policy template updated; accountability language updated.
  • Review approved 11/10/08: Background section/policy template updated.
  • Initial committee approval and effective 05/04/06
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  •  State Medicaid
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2010 edition
Definitions:
  • Modifier 24: used to indicate that the same physician needed to perform an Evaluation and Management (E&M) service unrelated to the original procedure during the postoperative period of the original service. E&M services performed during the postoperative period of the original service usually are considered part of the global surgical package.
  • Reimbursement Policy Definitions
Related Policies:
Modifier Usage
 
Related Material:

None

     expand Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Effective Date:3/2/2006
Policy:

Amerigroup allows limited reimbursement for physician claims billed with Modifier 25, unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements.

Reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated rate for the significant, separately identifiable Evaluation and Management (E&M) service performed by the same provider on the same day of the original service or procedure if the following criteria are met:

  • The appropriate level of E&M service is billed
  • Modifier 25 is appended to the E&M service, which is above and beyond the other service or procedure provided (including usual preoperative and postoperative care associated with the procedure)
  • The reason for the E&M service is clearly documented in the member’s medical record
  • The documentation supports that the member’s condition required the significantly separate E&M service

Failure to use Modifier 25 correctly may result in denial of the E&M service. Amerigroup reserves the right to perform postpayment review of claims submitted with Modifier 25.

 

Exemptions:
Amerigroup Florida allows reimbursement for an E&M visit resulting in the decision to perform a major surgery when billed with Modifier 25, in accordance with the Agency for Health Care Administration Medicaid Services Coverage and Limitations Handbook.
 
Policy History:
  • Review approved and effective 08/30/10: FL/NV exemptions added; postpayment review language added; Definitions, Background, and Related Policies sections updated; policy template updated
  • Review approved 11/10/08: Background section/policy template updated
  • Initial committee approval and effective 03/02/06
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  • State Medicaid
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2010 edition
Definitions:
  • Modifier 25: used to indicate that on the day a procedure or service was performed, the member’s condition required a significant, separately identifiable E&M service above and beyond the original service or above and beyond the usual preoperative and postoperative care associated with the original procedure. The E&M service may be prompted by the symptom or condition for which the procedure and/or service was performed so separate diagnoses codes are not required to report E&M codes on the same date. E&M services are not separately reimbursed from surgical and procedural services since these require appropriate provider involvement.
  • General Reimbursement Policy Definitions
Related Policies:
  • Modifier 57: Decision for Surgery
  • Modifier Usage
  • Preventive and Sick Visits on the Same Day
Related Material:
None
 
     expand Modifier 57: Decision for Surgery
Effective Date:4/9/2009
Policy:

Amerigroup allows separate reimbursement for an Evaluation and Management (E&M) visit provided on the day prior to or the day of a major surgery, when billed with Modifier 57 to indicate the E&M visit resulted in the initial decision to perform the major surgical procedure, unless provider, state, federal or CMS contracts or requirements indicate otherwise. A major surgery has a 90-day global period.

Reimbursement for the E&M visit is based on 100% of the applicable fee schedule or contracted/negotiated rate. Amerigroup reserves the right to request medical records for review to support payment for the E&M visit. Failure to use this modifier when appropriate may result in denial of the visit.

Nonreimbursable

Amerigroup does not allow reimbursement for services billed with Modifier 57 in the following circumstances, unless state, federal or CMS contracts or requirements indicate otherwise:

  • An E&M visit the day before or day of the surgery (e.g. preoperative evaluation), when the decision to perform the surgery was made prior to the E&M visit
  • An E&M visit for minor surgeries (0- or 10-day global period), since the decision to perform a minor surgery is usually reached the same day or day before the procedure, it is considered a routine preoperative service
  • A service with non-E&M codes
Exemptions:

Amerigroup Florida, Inc., in accordance with the Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations Handbook, allows reimbursement for an E&M visit resulting in the decision to perform a major surgery when billed with Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service). Claims for E&M visits billed with Modifier 57 will be considered for reimbursement as stated within the policy.

Policy History:
  • Review approved 04/23/12: Policy template updated
  • Review approved 04/25/11 and effective 04/09/09: language updated for clarity; Background section and policy template updated
  • Review approved 07/12/10 and effective 04/09/09: audit completed; Background section/policy template updated
  • Review approved 02/09/09 and effective 04/09/09:  FL exemption added; Background section/policy template updated
  • Review approved 07/25/06 and effective 05/22/06:  FL exemption to deny Modifier 57 removed
  • Initial committee approved and effective 05/22/06
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  •  State Medicaid
  • Amerigroup state contracts
  • American Medical Association: Coding with Modifiers, Third edition
  • Ingenix Learning: Understanding Modifiers, 2010 edition
Definitions:
Related Policies:
  • Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
  • Modifier Usage
Related Material:
None
     expand Modifier 59: Distinct Procedural Service
Effective Date:10/1/2012
Policy:
Amerigroup allows reimbursement for a procedure or service that is distinct or independent from other service(s) performed on the same day by the same provider when billed with Modifier 59, unless provider, state, federal, or CMS contracts or requirements indicate otherwise. When submitting a claim, providers must report Modifier 59 with the secondary procedure code, not the primary procedure code. If Modifier 59 is reported with the primary procedure code, the claim will be denied. Amerigroup reserves the right to perform post-payment review of claims submitted with Modifier 59. We may request additional documentation or notify the provider of additional documentation required for claims, subject to contractual obligations. If documentation is not provided following the request or notification, Amerigroup may recoup or recover monies previously paid on the claim, as provider failed to submit required documentation for post-payment review.

Nonreimbursable

Amerigroup does not allow reimbursement for Modifier 59 when:

  • Billed with Evaluation & Management (E&M) codes
  • Billed with radiation therapy management codes
  • A different modifier would describe the situation more accurately

[Note: Refer to individual modifier policies for specific modifier requirements, guidelines and exemptions.]

Exemptions:
None
Policy History:
  • Review approved February 27, 2012, and effective as follows:
    • Effective October 1, 2012, for Maryland, Nevada, New York, New Mexico, and Ohio
    • Effective October 1, 2012, for New Jersey
    • Effective October 1, 2012, for Florida, Georgia, Tennessee, Texas, Virginia, and new Amerigroup markets
    • Prepayment review requirements language removed; exemptions for multiple gestation and EPSDT removed
  • Review approved August 15, 2011, and effective as follows:
    • Effective October 11, 2009, for Maryland, Nevada, New York, New Mexico, and Ohio
    • Effective November 1, 2009, for New Jersey
    • Effective December 6, 2009, for Florida, Georgia, Tennessee, Texas, Virginia, and new Amerigroup markets
    • Exemption language added for multiple gestation diagnosis with fetal non-stress test
  • Review approved April 25, 2011, and effective as follows:
    • Effective October 11, 2009, for Maryland, Nevada, New York, New Mexico, and Ohio
    • Effective November 1, 2009, for New Jersey
    • Effective December 6, 2009, for Florida, Georgia, Tennessee, Texas, Virginia, and new Amerigroup markets
    • Summary of changes: post-payment review clarified; Florida note removed; language to refer to individual modifier policies added; list of related policies update; Background and Definitions sections updated; policy template updated
  • Review approved September 21, 2009, and effective as follows:
    • Effective October 11, 2009, for Maryland, Nevada, New York, New Mexico, and Ohio
    • Effective November 1, 2009, for New Jersey
    • Effective December 6, 2009, for Florida, Georgia, Tennessee, Texas, Virginia, and new Amerigroup markets
    • Summary of changes: documentation requirement for prepayment review, reimbursement for unsubstantiated or no documentation, and multiple procedure fee reduction clarified;
    • Florida exemption removed and clarified as a NOTE; EPSDT exemption added; Background section updated; Code and Clinical Editing Guidelines policy added to Related Policies/Procedures section.
  • Review approved and effective December 29, 2008: Prepayment review clarified; modifier definitions updated; Florida exemption added; Background section updated
  • Review approved and effective May 16, 2007: Retrospective review clarified
  • Original approved and effective: March 6, 2007
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  • State Medicaid
  • Amerigroup state Contracts
  • American Medical Association: Coding with Modifiers, Third edition
  • Ingenix Learning: Understanding Modifiers, 2010 Edition
  • U.S. Department of Health & Human Services, Office of the Inspector General, Semiannual Report to Congress, 1 October 2005 – 31 March 2006
  • U.S. Department of Health & Human Services, Office of the Inspector General, Use of Modifier 59 to Bypass Medicare’s National Correct Coding Initiative Edits, OEI-03-02-00771, November 2005
Definitions:
  • Modifier 59: Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures or services that are not normally reported together, but are appropriate under the circumstances. This may represent any of the following:
    • A different session
    • A different procedure or surgery
    • A different site or organ system
    • A separate incision or excision
    • A separate lesion
    • A separate injury (or are of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
  • Reimbursement Policy Definitions
Related Policies:
  • Claims Requiring Additional Documentation
  • Code and Clinical Editing Guidelines
  • Modifier Usage
  • Modifier 24: Unrelated Evaluation and Management Service by Same Physician during Postoperative Period
  • Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by Same Physician on Same Day of Procedure or Other Service
  • Modifier 57: Decision for Surgery
  • Modifier 78: Unplanned Return to Operating/Procedure Room by Same Physician Following Initial Procedure for a Related Procedure during Postoperative Period
  • Multiple and Bilateral Surgery
Related Material:
None
 
     expand Modifier 62: Co-surgeons
Effective Date:10/1/2006
Policy:

Amerigroup allows reimbursement of procedures eligible for co-surgeons when billed with Modifier 62, unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements.

Reimbursement to each surgeon is based on 62.5 percent of the applicable fee schedule or contracted/negotiated rate. Co-surgeons may be from the same specialty, or they may be from different specialties operating on separate body systems. Cosurgery is always performed during the same operative session.

Each surgeon must bill the same procedure code(s) with Modifier 62. If one or both surgeons fail to use the modifier appropriately, it is possible that one surgeon may receive 100 percent of the applicable fee schedule or negotiated/contracted rate, and the other surgeon’s claim may be denied or pended due to a duplicate or suspected duplicate service, respectively.

Assistant surgeon and/or multiple procedures rules and fee reductions apply if:

  • A co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session; and/or
  • Multiple procedures are performed
Exemptions:
Amerigroup Florida reimburses procedures eligible for co-surgeons appended with Modifier 62 at 60 percent to each provider, in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbooks.
 
Policy History:
  • Review approved 04/09/12; Background section and Policy template updated, added Louisiana and Nevada exemption
  • Review approved 05/17/10: No changes from original policy.
  • Review approved 11/10/08: No changes from original policy.
  • Initial committee approval: 06/06/06 and effective 10/01/06
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  • State Medicaid
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2010 edition
Definitions:
  • Modifier 62: used to indicate two surgeons, usually from different specialties, where the participation of both surgeons is necessary in performing a specific operative procedure. Two surgeons may be necessary due to the complex nature of the procedure(s) or the member’s condition.
  • General Reimbursement Policy Definitions
Related Policies:
  • Assistant at Surgery (Modifiers 80/80/82/AS)
  • Duplicate or Subsequent Services on the Same Date of Service
  • Modifier Usage
  • Multiple and Bilateral Surgery Reimbursement
Related Material:
Precertification Lookup Tool
 
     expand Modifier 63: Procedure Performed on Infants less than 4 kg
Effective Date:6/18/2012
Policy:
Amerigroup allows additional reimbursement for surgery on neonates and infants up to a present body weight of 4kg when billed with Modifier 63, unless provider, state, federal or CMS contracts or requirements indicate otherwise.
 
Reimbursement is based on 125 percent of the applicable fee schedule or contracted/negotiated rate for the procedure code when the modifier is valid for services performed. Medical records may be requested for review to support the additional payment. The neonate weight should be documented clearly in the report for the service.

When an assistant surgeon is used and/or multiple procedures are performed on neonates or infants less than 4kg in the same operative session, assistant surgeon and/or multiple procedure rules and fee reductions apply.

Nonreimbursable

Amerigroup does not allow reimbursement for Modifier 63 billed in the following circumstances including, but not limited to:
  • For facility billing
  • With Evaluation and Management (E&M) codes
  • With anesthesia codes
  • With radiology codes
  • With pathology/laboratory codes
  • With medicine codes
  • With Modifier 63-exempt codes
  • In addition to Modifier 22 (Unusual Services) for the same procedure code(s)
  • With codes denoting invasive procedures that include “neonate” or “infant” in the description (e.g. surgery to correct a congenital abnormality), since the reimbursement rate for the code already reflects the additional work
Exemptions:
  • Amerigroup Washington, Inc. does not recognize modifier 63 as a valid modifier, in compliance with Washington State Health Care Authority (HCA) Physician Related Services Manual.
  • Amerigroup Louisiana Inc. requires the submission of medical records if additional modifiers are billed with Modifier 63.
  • Amerigroup Florida, Inc. does not recognize Modifier 63 as a valid modifier in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations Handbook.
  • Amerigroup Georgia Managed Care Company, Inc. does not recognize Modifier 63 as a valid modifier in compliance with Georgia’s Department of Community Health Physicians Manual.
  • Amerigroup New York, LLC does not allow for reimbursement for more than 100% of the fee schedule amount or contracted/negotiated rate in compliance with the New York Department of Health Medicaid Physicians Manual.
Policy History:
  • Review approved and effective 06/18/12: Louisiana exemption added
  • Review approved 06/06/11 and effective 08/05/11: Background and Definitions sections updated; policy template update. GA and NY exemptions added; accountability language updated.
  • Review approved 10/06/08:  Background section/policy template updated.
  • Initial committee approval: 05/22/06 and effective: 10/01/06
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS
  • State Medicaid
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2010 edition
  • The Essential RBRVS, 2010 edition
Definitions:
Modifier 63: used to indicate a surgical procedure was performed on a neonate or infant up to a present body weight of 4kg. The modifier is intended to capture procedures performed on neonates and infants within a certain weight limit, as these procedures may involve significantly increased complexity and physician work.
Related Policies:
  • Assistant at Surgery (Modifiers 80/81/82/AS)
  • Modifier Usage
  • Multiple and Bilateral Surgery
Related Material:
None
     expand Modifier 66: Surgical Teams
Effective Date:5/21/2012
Policy:

Amerigroup allows reimbursement of procedures eligible for surgical teams when billed with Modifier 66, unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements.

Amerigroup performs prepayment review to support use of Modifier 66. Providers must submit documentation with claims billed with Modifier 66. Claims submitted without documentation will be denied.

Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66. If any or all physicians participating in the surgery fail to use the modifier appropriately, claims may be denied or pended for duplicate or suspected duplicate services, respectively.

Multiple procedure rules and fee reductions apply if the surgical team performs multiple procedures unless surgeons of different specialties are each performing a different procedure. Assistant surgery rules and fee reductions apply if any member of the surgical team acts as an assistant performing additional procedure(s) during the same surgical session.

Exemptions:

Amerigroup Florida reimburses procedures eligible for surgical teams in compliance with Florida’s Agency for Health Care Administration Medicaid Services Coverage and Limitations handbooks. Reimbursement is limited to physicians performing organ transplants only. Also, surgical team reimbursement is limited to a maximum of three physicians, and an operative report is required when more than one procedure is performed.

 

Policy History:
  • Review approved 05/21/12: Texas, Maryland and Washington exemptions added; Policy template updated
  • Review approved 05/17/10: Language added regarding documentation requirements; Background and Related Policies/Procedures sections and definitions updated.
  • Review approved 11/10/08: No changes from original policy.
  • Initial committee approval and effective 07/10/06
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  • State Medicaid
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2010 edition
Definitions:
  • Modifier 66: used in circumstances where highly complex procedures or the nature of the member’s condition require the services of a surgical team.
    • A surgical team consists of more than two physicians from different specialties performing different procedures (identified by different procedure codes), other highly skilled, specially trained personnel and various types of complex equipment.
    • The surgical team concept is performed during the same operative session. Surgical teams may be appropriate for procedures which include, but are not limited to, organ transplants, surgeries on multiple organ systems, amputation, coronary artery bypass, surgery of the skull base to remove tumors or certain vertebral body resections.
  • General Reimbursement Policy Definitions
Related Policies:
  • Assistant at Surgery (Modifiers 80/80/82/AS)
  • Claims Requiring Additional Documentation
  • Duplicate or Subsequent Services on the Same Date of Service
  • Modifier Usage
  • Multiple and Bilateral Surgery Reimbursement
Related Material:
None
     expand Modifier 76: Repeat Procedure by the Same Physician
Effective Date:5/5/2010
Policy:
Amerigroup allows reimbursement for applicable procedure codes appended with Modifier 76 to indicate a procedure or service was repeated by the same physician:
  • Subsequent to the original procedure or service for professional provider claims
  • On the same date as the original procedure or service for facility claims
Unless provider, state, federal, or CMS contracts or requirements indicate otherwise, reimbursement is based on the following use of Modifier 76:
  • For a nonsurgical procedure or service: 100 percent of the applicable fee schedule or contracted/negotiated rate
  • For a surgical procedure: 100 percent of the applicable fee schedule or contracted/negotiated rate for the surgical component only limited to a total of two surgical procedures

Professional services, other than radiology, which are excluded from this requirement, will be subject to clinical review for consideration of reimbursement. Providers must submit supporting documentation for the use of Modifier 76 with the claim. If a claim is submitted with Modifier 76 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 76 when appropriate may result in denial of the procedure or service.

If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply.

Nonreimbursable

Amerigroup does not allow reimbursement for use of Modifier 76:

  • With an inappropriate procedure code (e.g., laboratory/pathology)
  • For a surgical procedure repeated more than once
  • For the preoperative or postoperative components of a surgical procedure
Exemptions:
There are no exemptions to this policy.
Policy History:
  • Review approved March 26, 2012, and effective May 5, 2010: Accountability language updated
  • Review approved December 8, 2009, and effective May 5, 2010: Exclusive use of modifier on professional claims for procedures performed on the same date removed; modifier non-applicability to facility claims removed; definition of subsequent added
  • Review approved March 23, 2009: Radiology claim auto-adjudication clarified
  • Review approved October 20, 2008: Background section/policy template updated
  • Review approved August 15, 2007: Florida exemption removed
  • Initial committee approval: May 22, 2006, and effective: January 1, 2001
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS 
  • State Medicaid 
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2012 Edition
  • McKesson ClaimCheck® Code Edit Guidelines
Definitions:
  • Subsequent: the time period after the initial procedure or service is performed and within the global period designated for that procedure or service.
  • Reimbursement Policy Definitions

 
Related Policies:
  • Assistant at Surgery (Modifiers 80/81/82/AS)
  • Modifier Usage
  • Multiple and Bilateral Surgery Reimbursement
Related Material:
None
     expand Modifier 77: Repeat Procedure by Another Physician
Effective Date:8/27/2012
Policy:
Amerigroup allows reimbursement for applicable procedure codes appended with Modifier 77 to indicate a procedure or service was repeated by another physician:
  • Subsequent to the original procedure or service for professional claims
  • On the same date as the original procedure or service for facility claims
Unless provider, state, federal, or CMS contracts or requirements indicate otherwise, reimbursement is based on the following use of Modifier 77:
  • For a nonsurgical procedure or service: 100 percent of the applicable fee schedule or contracted/negotiated rate
  • For a surgical procedure: 100 percent of the applicable fee schedule or contracted/negotiated rate for the surgical component only limited to a total of two surgical procedures

Professional services, other than radiology, which are excluded from this requirement, will be subject to clinical review for consideration of reimbursement. Providers must submit supporting documentation for the use of Modifier 77 with the claim. If a claim is submitted with Modifier 77 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 77 when appropriate may result in denial of the procedure or service.

If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply.

Nonreimbursable

Amerigroup does not allow reimbursement for use of Modifier 77:

  • With an inappropriate procedure code (e.g., laboratory/pathology)
  • For a surgical procedure repeated more than once
  • For the preoperative or postoperative components of a surgical procedure
Exemptions:
  • The Amerigroup Florida Inc. contract with the state requires consistency with the Agency for Health Care Administration (AHCA). AHCA only recognizes Modifier 77 as a valid modifier when billed with radiology codes. Florida claims for nonradiological procedures submitted with Modifier 77 will be denied.
  • Amerigroup Washington, Inc., in compliance with Washington State Department of Social and Health Services and Health Care Authority, does not allow additional reimbursement of Modifier 77 (for informational purposes only).
Policy History:
  • WA exemption added and effective 08/27/2012.
  • Review approved March 26, 2012
  • Review approved June 20, 2011, and effective July 21, 2011: policy template updated; accountability language updated
  • Review approved December 8, 2009 and effective May 5, 2012: Exclusive use of modifier on professional claims for procedures performed on the same date removed; modifier non-applicability to facility claims removed; definition of subsequent added.
  • Review approved March 23, 2009 and effective April 27, 2009: Claim denial without supporting documentation clarified; radiology claim auto-adjudication clarified; Nonreimbursable section added; Background section/policy template updated
  • Initial committee approved and effective: May 22, 2006
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS
  • State Medicaid
  • Ingenix Learning: Understanding Modifiers, 2009 edition
  • McKesson ClaimCheck® Code Edit Guidelines
Definitions:
  • Subsequent: the time period after the initial procedure or service is performed and within the global period designated for that procedure or service.
  • Reimbursement Policy Definitions
Related Policies:
  • Assistant at Surgery (Modifiers 80/81/82/AS)
  • Modifier Usage
  • Multiple and Bilateral Surgery Reimbursement
Related Material:
None
     expand Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period
Effective Date:5/4/2006
Policy:
Amerigroup allows reimbursement for procedure codes appended with Modifier 78 when the procedure represents an unplanned return to the operating or procedure room by the same physician following the initial procedure for a related procedure during the postoperative period, unless otherwise noted by provider, state, federal and CMS contracts or requirements.
  • Reimbursement is based on 70 percent of the fee schedule or contracted/negotiated rate of the procedure if the modifier is valid for services performed.
  • Reimbursement is based on the surgical procedure only, not including preoperative or postoperative care. Procedures rendered during the postoperative period and not billed with Modifier 78 are normally denied as included in the global surgical package.
  • When an assistant surgeon is used and/or multiple procedures are performed during the global period in the same operative session, assistant surgeon and/or multiple procedure rules and fee reductions apply.

Nonreimbursable

  • Amerigroup does not allow reimbursement for Modifier 78 billed with nonsurgical codes and codes denoting subsequent, related or redo in the description.
Exemptions:
Amerigroup Florida Inc. does not recognize a reduction in reimbursement for Modifier 78. Reimbursement is based on 100 percent of the fee schedule or contracted/negotiated rate of the applicable surgical procedure code.
 
Policy History:
  • Review approved 10/20/08: Modifier definition updated
  • Review approved 03/27/07: FL exemption added
  • Initial committee approval 05/22/06 and effective 10/01/06
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS
  • State Medicaid
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2008 edition
  • McKesson ClaimCheck™ Code Edit Guidelines
Definitions:
Related Policies:
  • Assistant at Surgery (Modifiers 80/81/82/AS)
  • Modifier Usage
  • Multiple and Bilateral Surgery Reimbursement
Related Material:
Precertification Look Up Tool (PLUTO)
 
     expand Modifier 91: Repeat Clinical Diagnostic Laboratory Test
Effective Date:5/22/2006
Policy:

Amerigroup allows reimbursement of claims for clinical diagnostic laboratory tests appended with Modifier 91, unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements.

Reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated rate of the clinical diagnostic laboratory test billed with Modifier 91.

Failure to use the modifier appropriately may result in denial of the repeated laboratory test as a duplicate service.

 

Exemptions:
There are no exemptions to this policy.
 
Policy History:
  • Review approved and effective 06/21/10: Florida exemption removed; Background and Definitions sections updated; policy template updated
  • Review approved 11/10/08: Background section/policy template updated
  • Initial committee approval and effective 05/22/06
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  • State Medicaid
  • Amerigroup State Contracts
  • Ingenix Learning: Understanding Modifiers, 2010 edition
  • The Essential RBRVS, 2010 edition
Definitions:
  • Modifier 91: used to indicate a clinical diagnostic laboratory test was repeated on the same day for the same member to obtain multiple test results. Modifier 91 may not be used in the following situations:
    • To repeat a test to confirm initial results, or because there was a problem with the specimen or equipment when performing the initial test; or
    • When other code(s) describe a series of test results
  • General Reimbursement Policy Definitions
Related Policies:
Modifier Usage
 
Related Material:
Precertification Look Up Tool (PLUTO)
 
     expand Modifier Usage
Effective Date:3/14/2013
Policy:
Amerigroup allows reimbursement for covered services provided to eligible members when billed with appropriate procedure codes and appropriate modifiers when applicable, unless provider, state, federal, or CMS contracts or requirements indicate otherwise.
 
Reimbursement is based on code-set combinations submitted with correct modifiers. Certain modifiers require supporting documentation to be submitted with the claim. Refer to the Specific Modifier policies (Exhibit A) for guidance on documentation submission.
 
Applicable electronic or paper claims billed without the correct modifier in the correct format may be rejected or denied. The modifier must be in capital letters if alpha or alphanumeric. Providers must resubmit with the correct modifier in conjunction with the code set for the claim to be considered for reimbursement. Claims corrected and resubmitted are subject to timely filing guidelines. Use of correct modifiers does not guarantee reimbursement.
 
Reimbursement Modifiers
Reimbursement modifiers must be billed in the primary or first modifier field locator. These modifiers affect payment and denote circumstances when an increase or reduction is appropriate for the service provided.
Informational Modifiers Impacting Reimbursement
Informational modifiers that impact reimbursement should be billed in modifier locator fields after reimbursement modifiers if any. These modifiers determine if the service provided will be reimbursed or denied.
Informational Modifiers Not Impacting Reimbursement
Informational modifiers that do not impact reimbursement should be billed in subsequent modifier field locators. These modifiers are used for documentation purposes.
In the absence of state-specific modifier guidance, Amerigroup will default to CMS guidelines.
 
Exemptions:
There are no exemptions to this policy.
 
Policy History:
  • Review approved 07/30/12 and effective 03/14/13: added CMS default language; Exhibit A updated; policy template and background section updated.
  • Review approved February 14, 2011: claims rejection/denial and resubmission requirements clarified; modifier requirements clarified; Florida exemption removed; Amerigroup Reimbursement Modifiers Listing (Exhibit A) added; background and related policies sections updated; policy template updated
  • Review approved April 24, 2007: reimbursement and informational modifiers clarified; acceptable modifier format clarified; reordering modifiers for correct reimbursement clarified; Florida exemption added; policy template updated
  • Initial committee approval and effective: March 30, 2006
Reference and Research Material:

This policy has been developed through consideration of the following:

  • CMS
  • State Medicaid
  • Amerigroup state contracts
  • Ingenix Learning: Understanding Modifiers, 2010 edition
  • The Essential RBRVS, 2010 edition
Definitions:
Related Policies:
  • Assistant at Surgery (80/81/82/AS)
  • Claims Timely Filing
  • Duplicate Services on the Same Date of Service
  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
  • Modifier 22 Increased Procedural Service
  • Modifier 24 Unrelated Evaluation and Management Service by Same Physician during Postoperative Period
  • Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by Same Physician on Same Day of Procedure or Other Service
  • Modifier 57 Decision for Surgery
  • Modifier 59 Distinct Procedural Service
  • Modifier 62 Co-surgeons
  • Modifier 63 Procedure on Infants Less Than 4kg
  • Modifier 66 Surgical Teams
  • Modifier 76 Repeat Procedure by Same Physician
  • Modifier 77 Repeat Procedure by Another Physician
  • Modifier 78 Unplanned Return to Operating/ Procedure Room by Same Physician Following Initial Procedure for a Related Procedure during Postoperative Period
  • Modifier 91 Repeat Laboratory Test
  • Modifier LT and RT Left Side-Right Side Procedures
  • Multiple Bilateral Surgery Professional and Facility Reimbursement
  • Obstetrical Services
  • Physician Standby Services
  • Preadmission Services
  • Portable-Mobile-Handheld Radiology
  • Preventive and Sick Visits on the Same Day
  • Professional Anesthesia Services
  • Reduced or Discontinued Services (52/53/73/74)
  • Split Care Modifiers (54/55/56)
  • Telemedicine
  • Transportation Services
  • Vaccines for Children
Related Material:
     expand Modifiers LT and RT: Left Side/Right Side Procedures
Effective Date:6/6/2007
Policy:
Amerigroup allows reimbursement for procedure codes appended with Modifier LT and/or RT when indicating the side of the body for which the item, supply or procedure will be used unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.
 
Reimbursement is based on 100 percent of the fee schedule or contracted/ negotiated rate of the procedure. Modifiers LT and RT are informational modifiers; and therefore, do not increase or decrease reimbursement of the procedure.

It is inappropriate to use Modifier LT or Modifier RT when billing for bilateral procedures, or with procedure codes containing “bilateral” or “unilateral or bilateral” in their description. Modifiers LT and RT do not indicate a bilateral service. Claims submitted with Modifier LT and RT appropriately indicating a surgical procedure was performed on both the left side and right side of the body are subject to multiple surgery rules.
Exemptions:
There are no exemptions to this policy.
 
Policy History:
  • Review approved 11/07/11 and effective 06/06/07: background section/policy template updated; language regarding indicating side of body added.
  • Review approved 12/01/08: Background section/policy template updated.
  • Initial committee approval and effective 06/06/07
Reference and Research Material:
This policy has been developed through consideration of the following:
  • CMS
  • State Medicaid
  • Amerigroup state  contracts
  • Ingenix Learning: Understanding Modifiers, 2008 edition
Definitions:
Related Policies:
  • Modifier Usage
  • Multiple and Bilateral Surgery Reimbursement
Related Material:
None
     expand Reimbursement for Reduced and Discontinued Services
Effective Date:12/9/2012
Policy:
Amerigroup allows reimbursement to professional providers and facilities (i.e., outpatient hospital/ambulatory surgery center) for reduced or discontinued services when appended by the appropriate modifier, unless provider, state, federal, or CMS contracts or requirements indicate otherwise. Reimbursement is based on the following:
  • Append Modifier 52 to indicate:
    • Professional provider billing when a procedure that may or may not require anesthesia was reduced or eliminated at the physician’s discretion
    • Facility billing when a radiology procedure that does not require anesthesia was reduced
    • Reimbursement is reduced to 50 percent of the applicable fee schedule or contracted/negotiated rate
  • Append Modifier 53 to indicate:
    • Professional provider billing when a procedure was terminated after anesthesia was administered
    • Reimbursement is reduced to 50 percent of the applicable fee schedule or contracted/negotiated rate
    • Modifier 53 is not applicable for facility billing
  • Append Modifier 73 to indicate:
    • Facility billing when a procedure stopped before anesthesia was administered
    • Reimbursement is reduced to 50 percent of the applicable fee schedule or contracted/negotiated rate
    • Modifier 73 is not applicable for professional provider billing
  • Append Modifier 74 to indicate:
    • Facility billing when a procedure was stopped after anesthesia
    • Reimbursement is 100 percent of the applicable fee schedule or contracted/negotiated rate
    • Modifier 74 is not applicable for professional provider billing
If the reduced or discontinued procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon, and/or multiple procedure rules and fee reductions apply. Amerigroup reserves the right to perform post-payment review of claims submitted with modifiers 52, 53, 73 and 74.
      Exemptions:
      • Amerigroup Florida Inc., in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbooks:
        • Allows reimbursement of claims with Modifier 52 at 90 percent of the applicable fee schedule or contracted/negotiated rate
        • Does not recognize modifier 53
      • Amerigroup New Jersey, Inc. does not recognize Modifiers 53, 73 or 74 in compliance with the New Jersey Division of Medical Assistance and Health Services provider manuals.
      • Amerigroup Ohio Inc. does not recognize Modifiers 52 or 53 in compliance with the Ohio Department of Job and Family Services provider manuals.
      • Amerigroup Washington, Inc., in compliance with Washington State Department of Social and Health Services and Health Care Authority:
        • Does not allow reduced reimbursement of claims with modifier 52
        • Only recognizes modifier 53 for certain colonoscopy procedure and screening codes; for all other procedures the modifier is informational
      Policy History:
      Initial committee approval 04/09/12 and 12/09/12: Policy adapted from Modifier 53: Discontinued Procedure #06-022
      Reference and Research Material:
      This policy has been developed through consideration of the following:
      • CMS
      • State Medicaid
      • Amerigroup state contracts
      • Ingenix Learning: Understanding Modifiers, 2010 Edition
      Definitions:
      Related Policies:
      • Assistant at Surgery (Modifiers 80/81/82/AS)
      • Modifier Usage
      • Multiple and Bilateral Surgery Reimbursement
      Related Material:
      None
           expand Reimbursement of Services with Obsolete Codes
      Effective Date:6/6/2007
      Policy:

      In compliance with industry-standard coding practices according to the Health Insurance Portability and Accountability Act (HIPAA), Amerigroup does not allow reimbursement for services billed with obsolete codes. Billing with obsolete codes is not HIPAA compliant.

      Claims submitted for services using obsolete codes will be denied.  Providers must resubmit claims with applicable new or replacement codes in order for the services to be considered for reimbursement. Resubmitted claims are subject to claims timely filing guidelines.

       

      Exemptions:

      This policy does not apply to a state that has received a federal waiver to allow a noncompliant obsolete code.

       

      Policy History:
      • Review approved February 14, 2011: claims timely filing language added; background and related policies sections updated; policy template updated
      • Review approved December 24, 2008: background section/policy template updated
      • Initial committee approval and effective: June 6, 2007
      Reference and Research Material:
      This policy has been developed through consideration of the following:
      • CMS
      • State Medicaid
      • Amerigroup State Contracts
      • National Correct Coding Initiative
      • HIPAA Compliance Guidelines
      • Sarbanes-Oxley Compliance Guidelines
      Definitions:
      Related Policies:
      • Claims Timely Filing
      • Code and Clinical Editing Guidelines
      Related Material:
      None
       
           expand Unlisted or Miscellaneous Codes (aka Dump Codes)
      Effective Date:9/13/2010
      Policy:

      Amerigroup allows reimbursement for unlisted or miscellaneous codes (aka: dump codes) in accordance with specified guidelines unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure or item rendered.

      Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis. Claims submitted with unlisted or miscellaneous codes must contain the following information and/or documentation for consideration during review:

      • A written description, office notes, or operative report describing the procedure or service performed
      • An invoice and written description of items, supplies, and/or drugs
      • An unlisted drug code must be billed with a corresponding National Drug Code (NDC) number
      Exemptions:
      • Amerigroup Nevada Inc. allows reimbursement of unlisted drug codes submitted without a written description of the drug(s) when billed with a corresponding National Drug Code (NDC) number. Amerigroup reserves the right to request medical records to support the claim.
      • Amerigroup Ohio Inc. allows facilities to bill certain surgical unlisted codes without documentation of a written description, office notes, or operative report describing the procedure or service performed and to be reimbursed based on a percentage determined by the state of Ohio or the provider’s contract. Amerigroup reserves the right to request medical records to support the claim. [NOTE: This exemption does not apply if the facility provides a description for the unlisted code and an established code exists to describe the service.]
      • Amerigroup Texas Inc. and Amerigroup Insurance Company allow reimbursement of some unlisted codes submitted without documentation of a written description, office notes or operative report when the code is appended with an applicable modifier. Amerigroup reserves the right to request medical records to support the claim. [NOTE: This exemption does not apply if the provider includes a description for the unlisted code and an established code exists to describe the service.]
      Policy History:
      • Update approved 11/21/11 and effective 09/13/10: Accountability language updated; Nevada exemption added.
      • Review approved and effective 09/13/10: TX exemption added; Background section and policy template updated
      • Review approved 09/21/09 and effective as follows:
        • Effective 11/01/09 for NJ
        • Effective 10/11/09 for all other and new Amerigroup markets

      Summary of changes: Requirement for licensed clinician medical review removed; medical criteria for review removed; OH exemption for NDC number removed (contract term).

      • Review approved 10/06/08: OH exemption for surgical unlisted codes added.
      • Review approved 05/29/07: OH exemption for NDC number added.
      • Review approved 04/10/07: Requirement for NDC number added; medical review criteria clarified.
      • Initial committee approval: 03/02/06
      Reference and Research Material:

      This policy has been developed through consideration of the following:

      • CMS
      • State Medicaid
      • Amerigroup state contracts
      Definitions:

      Unlisted or Miscellaneous Codes are used for service(s) or item(s):

      • Not having a designated code fitting the description of the service(s) or item(s) rendered (aka: catch-all code)
      • To circumvent:
        • Code edit software logic, such as:
          • Duplicate claim
          • Incident to
          • Mutually exclusive
          • Unbundling logic
        • Benefit limitations and exclusions (noncovered services)
        • Fee allowances (maximize reimbursement)

      Unlisted or Miscellaneous Codes may be used for a variety of services or items. As new and advanced approaches and techniques are under development, the Unlisted category is used for auditing purposes until these procedures become accepted in medical practice and are routinely performed by providers. Specific fee allowances and/or Relative Value Units (RVUs) cannot be established for Unlisted services or items.

      Reimbursement Policy Definitions

      Related Policies:
      None
       
      Related Material:
      None
       
      collapse DME & Supplies
           expand Facility Take-home Durable Medical Equipment and Medical Supplies
      Effective Date:12/22/2009
      Policy:
      Amerigroup does not allow reimbursement of Durable Medical Equipment (DME) and medical supplies dispensed by a facility for take-home use under the inpatient or outpatient hospital benefit.
      • Facility claims submitted for DME and medical supplies billed with revenue codes indicating take-home use (i.e., use outside of a facility) will be denied.
      • To be considered for reimbursement, claims for take-home DME and medical supplies should be submitted by a DME/supply vendor.
      • Reimbursement is based on the:
        • Contract or negotiated rate for participating vendors
        • Out-of-network fee schedule or negotiated rate for nonparticipating vendors
      • Amerigroup allows reimbursement of facility claims for medical supplies dispensed to the member at discharge and billed with revenue codes other than take-home (e.g., general supplies) for the following items:
        • Crutches
        • Medical supplies for no more than a 72-hour period if the provider was not able to obtain supplies from a vendor by the time of discharge
      Exemptions:
      There are no exemptions to this policy.
       
      Policy History:
      • Review approval 08/10/09 and effective 12/22/09: Take-home medical supplies and use of revenue codes clarified.
      • Initial committee approval and effective 09/06/06
      Reference and Research Material:
      This policy has been developed through consideration of the following:
      • CMS State Medicaid
      • Amerigroup State Contracts
      Definitions:
      Related Policies:
      • Durable Medical Equipment
      • Modifiers for new, used and rented equipment
      Related Material:
      Precertification Look Up Tool (PLUTO)
       
      collapse Drugs
           expand Drugs and Injectable Limits
      Effective Date:12/9/2012
      Policy:
      Amerigroup allows reimbursement for drug claims received with HCPCS/CPT procedure codes that do not contain Medically Unlikely Edit (MUE) limits and are within the physical quantities of drugs also known as units, unless provider, state, federal, or CMS contracts or requirements indicate otherwise.
       
      Drug claims must be submitted as required with applicable HCPCS or CPT procedure code(s), National Drug Codes (NDCs), appropriate qualifier, unit of measure, number of units and price per unit. Units should be reported in the multiples included in the code descriptor used for the applicable HCPCS codes.
       
      Reimbursement will be considered up to the Clinical Unit Limits (CUL) allowed for the prescribed/administered drug. Amerigroup utilizes the CMS MUE value. When there is no MUE assigned by CMS, identified codes will have a CUL assigned or calculated based on the prescribing information, the Food and Drug Administration, and established reference compendia.
       
      Claims that exceed the CUL will be reviewed for documentation to support the additional units. If the documentation does not support the additional units billed, all units will be denied
      Exemptions:
      There are no exemptions to this policy.
      Policy History:
      Initial committee approval 06/18/12 and effective 12/09/12
      Reference and Research Material:
      This policy has been developed through consideration of the following:
      • CMS
      • State Medicaid
      • Amerigroup state contracts
      • The Food and Drug Administration
      Definitions:
      The appropriateness of the specific treatment for which a drug is being prescribed is recognized and supported in one of the following established reference compendia:
      • American Hospital Formulary Service Drug Information
      • National Comprehensive Cancer Network Drugs and Biologics Compendium
      • Thomson Micromedex DrugDex
      • Elsevier Gold Standard Clinical Pharmacology
      • General Reimbursement Policy Definitions
      Related Policies:
      • Unlisted and Miscellaneous Codes
      • Claims Submission – Required Information for Professional Providers
      Related Material:
      None
           expand Facility Take-home Drugs
      Effective Date:8/31/2006
      Policy:
      Amerigroup does not allow reimbursement of take-home drugs—those dispensed by a facility for take-home use under the inpatient or outpatient hospital benefit. Claims submitted by a facility for drugs with revenue codes denoting take-home use will be denied.
      Exemptions:
      Amerigroup Community Care of New Mexico Inc. allows reimbursement of the co-insurance and deductible, calculated after the Medicare payment, for claims submitted by I.H.S. and Tribal 638 facilities regardless of the service or revenue code billed, in compliance with State guidance.
      Policy History:
      • Review approved March 26, 2012
      • Review approved August 15, 2011: policy template updated
      • Update due to regulatory directive (Committee approval not required in accordance with Reimbursement Policy Program Guidelines, policy #05–017):
        • June 16, 2010 to add New Mexico exemption
      • Review approved May 30, 2012: Use of revenue codes clarified; benefit information removed; policy template updated
      • Review approved October 6, 2008: Background section/policy template updated
      • Initial committee approval and effective: August 31, 2006
      Reference and Research Material:
      This policy has been developed through consideration of the following:
      • CMS
      • State Medicaid
      • Amerigroup state contracts
      Definitions:
      Related Policies:
      None
      Related Material:
      None
      collapse Evaluation & Management
           expand Consultations
      Effective Date:5/1/2005
      Policy:

      Amerigroup allows reimbursement for consultations by physicians or qualified nonphysician practitioners (referred to as provider(s) throughout this policy) in accordance with specified guidelines unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements. Reimbursement is based on the fee schedule or contracted/negotiated rate based on one of the following:

      • The appropriate code designating a traditional consultation based on state Medicaid guidelines (i.e., for codes containing consultation in their description)
      • The appropriate code designating a consultation based on CMS guidelines

      Consultations

      Consultations are reimbursable according to the following guidelines:

      • The consultation must be specifically requested by the attending provider
      • The consultation service must be within the scope and practice of the consulting provider
      • The consulting provider must complete a written report that includes:
        • Member history, including chief diagnosis and/or complaint
        • Examination
        • Finding(s)
        • Recommendation(s) and/or ordered service(s)
      • The member’s medical record must contain:
        • The attending provider’s request for the consultation
        • The reason for the consultation
        • Documentation that indicates the information communicated by the consulting provider to the member’s attending provider and the member’s authorized representative, if required
        • The consulting provider’s written report
      • The reason for the consultation must be documented in the requesting provider’s plan of care
      • Laboratory consultations must relate to test results that are outside the clinically significant normal or expected range considering the member’s condition
      • Consultations performed through use of telemedicine applications (i.e., video teleconference) must comply with the Amerigroup Telemedicine Policy
      • The consulting provider may initiate diagnostic and/or therapeutic services at the same or subsequent visit:
        • If the consulting provider performs a definitive therapeutic surgical procedure on the same day as the consultation for the same member, the consultation must be reported with Modifier 25 or Modifier 57, whichever is most appropriate
        • If the appropriate modifier is not reported, the consultation is considered included in the reimbursement for the therapeutic surgical procedure and therefore not separately reimbursable

      Pre-operative Clearance and Postoperative Evaluation

      A surgeon may request a provider perform a consultation as part of either a pre-operative clearance or post-operative evaluation, as long as consultation guidelines are met in addition to the following:

      • A consulting provider may be reimbursed for a postoperative evaluation only if:
        • The requesting surgeon requires a professional opinion for use in treating the member
        • The consulting provider has not performed the pre-operative clearance
      • Postoperative visits are considered concurrent care and do not qualify forreimbursement as consultations if:
        • A consulting provider performs a pre-operative clearance
        • Subsequent management of all or a portion of the member’s postoperative care is transferred to the same consulting provider who performed the pre-operative clearance

      [NOTE: The following do not qualify as consultations:

      • Routine screenings
      • Routine pre-operative or postoperative management care, including but not limited to:
        • Member history and physical for the surgical procedure being performed
        • Services applicable to be billed with the surgical procedure code appended with Modifier 56
        • Services applicable to be billed with the surgical procedure code appended with Modifier 55]

      Consultation by a Primary Care Physician

      A Primary Care Physician (PCP) may perform a consultation for his/her own patient in the following circumstances:

      • If a surgeon has specifically requested the PCP to perform either a pre-operative clearance or a postoperative evaluation, as long as:
        • Consultation, pre-operative clearance and/or postoperative evaluation guidelines are met
        • Pre-operative and/or postoperative consultations rendered by the member’s PCP are reimbursable services based on state guidance or the provider’s contract

      The pre-operative visit is usually included in the surgeon’s global surgical allowance. Medical review may be required if the PCP is reimbursed for a service normally included in the global fee allowance (i.e., duplicate service).

      • If a behavioral health provider has specifically requested the PCP to perform a consultation to provide either a medical evaluation for a specific condition or a general medical evaluation (i.e., history and physical) on a member admitted to an inpatient psychiatric unit for behavioral health treatment. These occurrences usually are billed as Evaluation & Management (E&M) visits. Medical review may be required to ensure consultation guidelines are met.

      [NOTE: A PCP is responsible for the care of his/her own patient and therefore does not usually qualify to perform consultations because:

      • Such services are considered evaluations rather than consultations
      • The PCP has an established medical record and/or history on themember]

      Consultation within the Same Group Practice

      A consultation may be considered for reimbursement if the attending provider requests a consultation from another provider of a different specialty or subspecialty within the same group practice, as long as consultation guidelines are met.

      Nonreimbursable

      Amerigroup does not allow reimbursement for the following with regard to a consultation:

      • Performed by telephone [NOTE: telephone calls are not considered telemedicine]
      • Performed as a split or shared E&M visit
      • Performed in addition to an E&M visit for the same member by the same provider, unless Modifier 25 is appropriate
      • Performed as a second or third opinion requested by the member, member’s authorized representative or as mandated
      • Performed for noncovered services
      • When a transfer of care to the consulting provider occurs (i.e., subsequent visits for the same patient by the same consulting provider)
      • For both pre-operative clearance and postoperative evaluation of the same member by the same consulting provider for which the specified guidelines are not met
      Exemptions:
      There are no exemptions to this policy.
       
      Policy History:
      • Review approved 08/17/12: Policy template updated.
      • Policy definitions updated: September 15, 2011
      • Review approved August 16, 2010, and effective May 1, 2005: Consultation definition added; language differentiating Medicaid and CMS appropriate consultation codes added; medical references removed; policy template updated
      • Review approved December 1, 2008: Background section/policy template updated
      • Review approved April 10, 2007: Consultation guidelines clarified; pre-op and post-op consultations clarified; nonreimbursable section added
      • Initial committee approval: March 1, 2005, and effective May 1, 2005
      Reference and Research Material:
      This policy has been developed through consideration of the following:
      • CMS
      • State Medicaid
      • Amerigroup State Contracts
      • American Medical Association
      Definitions:

      Consultation: a deliberation by two or more providers with respect to the diagnosis and/or treatment in any particular case where the expertise, professional opinion and medical judgment of the consulting provider are considered necessary

      Second Opinion: an opinion obtained from an additional health care professional prior to the performance of a medical service or a surgical procedure. May relate to a formalized process, either voluntary or mandatory, which is used to help educate a patient regarding treatment alternatives and/or to determine medical necessity

      Reimbursement Policy Definitions

      Related Policies:
      • Modifier Usage
      • Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
      • Modifier 55: Postoperative Management Only
      • Modifier 56: Preoperative Management Only
      • Modifier 57: Decision for Surgery
      • Second and Third Opinions
      • Telemedicine
      Related Material:

      None

           expand Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
      Effective Date:11/8/2012
      Policy:
      Amerigroup allows reimbursement of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program services, unless provider, state, federal or CMS contracts or requirements indicate otherwise. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate.

      The following EPSDT component services are included in the reimbursement of the preventive medicine Evaluation and Management (E&M) visit, unless appended with Modifier 25 to indicate a significant, separately identifiable E&M service by the same physician on the same date of service:
      • Comprehensive health history
      • Comprehensive unclothed physical examination
      • Health education
      • Nutritional assessment
      • Hearing screening with or without the use of an audiometer or other electronic device
      • Dental screening
      • Vision screening

      The following component services are separately reimbursable from the preventive medicine E&M visit:

      • Developmental screening using a standardized screening tool
      • Immunization and administration
      • Laboratory tests:
        • Newborn metabolic screening test
        • Tuberculosis test
        • Hematocrit and hemoglobin tests
        • Lead toxicity screening
        • Cholesterol test
        • Pap smear, for sexually active members
        • Sexually Transmitted Disease (STD) screening, for sexually active members
        • Urinalysis

      Providers should follow periodicity guidelines established by the American Academy of Pediatrics and the Centers for Disease Control. If a provider performs EPSDT services in conjunction with a sick visit, all services are subject to the Amerigroup Preventive Medicine and Sick Visits on Same Day policy.

      Claims Requirements

      Provider claims for EPSDT services should include all of the following items:

      • EPSDT special program indicator
      • EPSDT referral indicator codes (a.k.a. referral condition codes) if applicable
      • Appropriate diagnosis code(s)
      • Appropriate HCPCS code identifying the completed EPSDT service (list in addition to code for appropriate E&M service)
      • Appropriate E&M codes for new or established members
      • Appropriate procedure code for the component services
      • Applicable modifier(s) in accordance with Exhibit B
      Exemptions:
      • Amerigroup Washington, Inc. requires the E&M code and the EPSDT screening procedure code on separate claim forms when the provider treats for a medical problem identified during an EPSDT screening examination in compliance with the Washington State Health Care Authority.
      • Amerigroup Florida, Inc. does not allow:
        • Separate reimbursement for developmental screening
        • Reimbursement for the vaccine serum; only the vaccine administration code is reimbursable, in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbooks
      • Amerigroup Georgia Managed Care Company, Inc. allows separate reimbursement for hearing screening services
      • Amerigroup Maryland, Inc. allows separate reimbursement for vision and hearing screening services
      • Amerigroup New Jersey, Inc. and Amerigroup Virginia, Inc. allow separate reimbursement for vision and hearing screening services
      • Amerigroup Ohio, Inc. allows separate reimbursement for hearing screening with the use of an audiometer.
      • Amerigroup Texas, Inc. and Amerigroup Insurance Company do not allow separate reimbursement for laboratory tests, except cholesterol screens when sent to an outside laboratory.
      Policy History:
      • Review approved and effective 10/08/12: Washington exemption added; Louisiana and Kansas market EPSDT modifiers added to Exhibit A; Florida exemption updated
      • Review approved 12/05/11 and effective 3/16/12:
        • Component service reimbursement clarified; lab tests by participating provider requirement removed; periodicity language added; FL/GA/MD/NJ/OH/TX/VA exemptions added; Exhibit A Market EPSDT Modifier Requirements added; policy template updated.
        • Other electronic device language added – Specific screening test per market removed.
      • Initial committee approval and effective: 08/09/06
      Reference and Research Material:
      This policy has been developed through consideration of the following:
      • CMS
      • State Medicaid
      • Amerigroup state contracts
      • American Academy of Pediatrics
      • Centers for Disease Control
      Definitions:
      Related Policies:
      • Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
      • Modifier Usage
      • Preventive Medicine and Sick Visits on the Same Day
      • Vaccines for Children Program
      Related Material:
           expand Physician Standby Services
      Effective Date:9/24/2012
      Policy:

      Amerigroup does not allow separate reimbursement for physician standby services unless provider, state, federal or CMS contracts or requirements indicate otherwise. Reimbursement for physician standby services is included in the applicable facility rate. Professional or facility claims submitted for separate reimbursement for physician standby services will be denied.

      Providers should not append Modifier 59, Distinct Procedural Service, to indicate physician standby services in order to receive separate or additional reimbursement. Claims billed with Modifier 59 to indicate physician standby services will be denied or subject to recovery or recoupment.

      If, during the standby period, the standby physician performs services therefore rendering direct care to the member, the standby physician may be separately reimbursed only for the professional services, subject to service coverage. The standby service will not be separately reimbursed.

      Services for attendance and initial stabilization of a newborn at a vaginal or cesarean delivery, at the request of the delivering physician when there is documented fetal distress or reasonable anticipation of newborn distress, are not considered physician standby services.

      [NOTE: Attendance and initial stabilization services are represented by a different procedure code than physician stabilization services.] 

      Attendance and initial stabilization of a newborn involves the physician rendering direct care to the newborn and therefore may be a separately reimbursable expense from the facility rate.

      Exemptions:
      • Amerigroup Washington, Inc. allows separate reimbursement for physician standby services only when the standby physician does not provide care or service to other clients during this period, and one of the following applies:
        • The services are provided in conjunction with newborn care history and examination or result in an admission to a neonatal intensive care unit on the same day.
        • A physician requests another physician to stand by resulting in the prolonged attendance by the second physician without face-to-face client contact.
      • Amerigroup Florida, Inc. allows separate reimbursement for physician standby services only for cesarean delivery of normal newborns if standby criterion is met (30 minutes or more) in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbook. The physician standby service is not allowed separate reimbursement in addition to attendance and initial stabilization of a newborn.
        Policy History:
        • Review approved and effective 09/24/12: Washington exemption added.
        • Review approved 02/28/11 and effective 12/07/2011: SC exemption removed; Background and Definitions sections updated; policy template updated
        • Review approved 06/11/09: Medical criteria references removed; SC exemption updated for market departure; Background section updated
        • Initial committee approval and effective: 05/16/07
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        Physician standby services: represents occasions where the physician is present and available for a prolonged period, at the request of the primary physician, in case the standby physician’s specific expertise and skills become necessary in the treatment of a member. The physician is not rendering direct care to the respective or any other member during standby.
         
        Related Policies:
        Modifier 59: Distinct Procedural Service
        Related Material:
        None
             expand Preventive Medicine and Sick Visits on the Same Day
        Effective Date:4/1/2010
        Policy:
        Amerigroup allows reimbursement for preventive medicine (i.e., well-child) and limited sick visits on the same day, unless provider, state, federal, or CMS contracts or requirements indicate otherwise. Reimbursement is based on the fee schedule or contracted/negotiated rate for the preventive medicine and the allowed sick visit under the following conditions:
        • Modifier 25 must be billed with the applicable Evaluation and Management (E&M) code for the allowed sick visit. If Modifier 25 is not billed appropriately, the sick visit will be denied.
        • Appropriate diagnosis codes must be billed for respective visits.
        Exemptions:
        • Amerigroup Texas, Inc and Amerigroup Insurance Company allow reimbursement for a new checkup and a new evaluation and management visit when both are performed on the same day if the member meets the requirements as a new patient.
        • Amerigroup Florida, Inc. does not allow reimbursement for preventive medicine and sick visits on the same day. If both are billed for the same day, reimbursement is allowed only for the preventive medicine visit. The sick visit will be denied.
        • Amerigroup Maryland, Inc. hospital-based clinic facility claims are not subject to this policy.
        • Amerigroup Ohio, Inc. does not limit the sick visit. If preventive medicine and sick visits are billed for the same day, reimbursement is allowed for any sick visit billed with modifier 25, in addition to the preventive medicine visit.

        Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) reimbursed other than through their respective health plan’s fee schedule or state encounter rates are not subject to this policy.

        Policy History:
        • Review approved 05/21/12: allowable sick visits language removed; Policy template updated
        • Review approved 11/21/11 and effective 04/01/10: policy template updated; TX exemption added; state encounter rate language added
        • Review approved 01/25/2010 and effective 04/01/2010: Limits on allowable sick visits added; SC exemption removed due to exit from market; MD, FQHC, and RHC exemptions added.
        • Review approved 07/31/09: NV exemption removed.
        • Review approved 03/09/09: Clarification of appropriate diagnosis code requirement added; medical criteria for minor illnesses and conditions removed; NV exemption added; SC exemption updated; Background section/policy template updated
        • Review approved 05/30/07: Claim denial without Modifier 25 clarified; SC exemption added
        • Initial committee approval and effective: 09/01/05
        Reference and Research Material:
        This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status, in addition to the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Code and Clinical Editing Guidelines
        • Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
        Related Material:
        None
        collapse Facilities
             expand Preadmission Services for Inpatient Stays
        Effective Date:9/28/2007
        Policy:
        Amerigroup allows reimbursement for applicable services for a covered member prior to admission to an inpatient hospital (referred to as the payment window), unless otherwise noted by provider, state, federal or CMS contracts and/or requirements, based on CMS guidance as follows:
        • For admitting hospitals, applicable pre-admission services are included in the inpatient reimbursement for the three days prior to and including the day of the member’s admission; and therefore, are not separately reimbursable expenses [NOTE: including any entity wholly owned or wholly operated by the admitting hospital or by another entity under arrangements with the admitting hospital (i.e., the admitting hospital owns the physician’s practice performing the pre-admission services)]
        • For other hospitals and units, applicable pre-admission services are included in the inpatient reimbursement within one day prior to and including the day of the member’s admission; and therefore, are not separately reimbursable expenses, including:
          • Psychiatric hospitals and units
          • Inpatient rehabilitation facilities and units
          • Long-term care hospitals
          • Children’s hospitals
          • Cancer hospitals
        • For Critical Access Hospitals, pre-admission services are not subject to either the three-day or the one-day payment window; and therefore, are separately reimbursable expenses from the inpatient stay reimbursement

        Pre-admission Services:

        Applicable pre-admission services consist of diagnostic and limited nondiagnostic (e.g., therapeutic) services performed on an outpatient basis prior to an inpatient stay that are related to the member’s hospital admission. Applicable nondiagnostic services are those that directly relate to the member’s hospital admission (i.e., the outpatient principal diagnosis for the nondiagnostic service exactly matches (all digits) the inpatient principal diagnosis). Related diagnostic and directly related nondiagnostic services are considered inpatient services and are included in the inpatient reimbursement.

        Unrelated diagnostic services and nondiagnostic services (i.e., not directly related to the inpatient stay) are considered separately reimbursable outpatient expenses.

        Nonreimbursable:

        • Amerigroup does not consider the following services to be included in the payment window prior to an inpatient stay [NOTE: these services may be considered for separate outpatient reimbursement]:
          • Ambulance services
          • Maintenance renal dialysis services
          • Services provided by:
            • skilled nursing facilities
            • home health agencies
            • hospices
        Exemptions:
        Amerigroup Maryland requires providers to bill outpatient preadmission services with the inpatient claim, although the services are separately reimbursed in accordance with the Health Services Cost Review Commission guidelines.
        Policy History:
        • Review approved 12/05/11 and effective 09/28/07: background section updated; policy template updated
        • Review approved 083010: Background section and definitions updated; policy template updated.
        • Initial committee approval 05/31/07 and effective 09/28/07
        • Review approved and effective 04/10/09: Policy change to adopt CMS guidelines versus 7-day payment window; medical examples of diagnostic and non-diagnostic services removed; MD exemption clarified; Background section/policy template updated
        Reference and Research Material:
        This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status, in addition to the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        • U.S. Department of Health and Human Services, Office of the Inspector General Final Report, Expansion of the Diagnosis Related Group Payment Window, A-01-02-00503, August 2003
        Definitions:
        Related Policies:
        None
         
        Related Material:
        None
         
        collapse Medicine
             expand Allergy Treatment: Immunotherapy
        Effective Date:12/7/2011
        Policy:
        Amerigroup allows reimbursement for allergy immunotherapy unless provider, state, federal, or CMS contracts or requirements indicate otherwise. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate for:
        • The injection service component code and the antigen dosage/ preparation component code (per dose) billed separately:
          • Claims submitted with a procedure code representing the complete service (collectively including the injection service, antigen dose and the antigen preparation) will be denied.
          • If the antigen is prepared other than in the physician’s office, the physician may bill only for the injection services.
          • Physicians using treatment boards must bill with the component codes, even though they prepare no vials.
          • If multiple antigen doses are prepared in the same setting, either:
            • The injection service and the antigen dosage/preparation service indicating the number of dosages for the injection is administered during the first visit.
            • The injection service only for remaining injections is administered during subsequent visits.
              [Note: Amerigroup allows reimbursement of up to 20 doses billed for preparation of single or multiple antigen doses during a 30-day period. Claims billed for more than 240 doses during a 12-month period will be denied.]
        • A reasonable supply of antigens prepared for a member (i.e., 12-month supply)

        Providers may not bill for Evaluation and Management (E&M) visits for established patients on the same day as allergy injection services unless the E&M visit represents a significant, separately identifiable service and is appended with Modifier 25. Claims submitted for an E&M visit in conjunction with allergy injection services without the Modifier 25 will be denied. Claims submitted for E&M visits for new patients on the same day as allergy injection services may be reviewed for medical necessity.

        Exemptions:
        • Amerigroup Texas, Inc. and Amerigroup Insurance Company allow reimbursement for up to 160 doses billed for preparation of single or multiple antigen doses during a one-year period, in compliance with the Texas Medicaid Provider Procedures Manual.
        • Amerigroup Florida, Inc. allows reimbursement for up to 25 doses billed for preparation of single or multiple antigen doses during a 30-day period, in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations Handbook.
        Policy History:
        • Review approved and effective 06/18/12: Language updated for clarity
        • Review approved 05/24/11 and effective 12/7/11; Texas exemption added; Amerigroup Medicare Advantage exemption removed; Background/Definitions sections updated; policy template updated; Florida exemption added
        • Review approved 06/01/09:  Medical criteria and benefit coverage information removed; background section updated.
        • Review approved 04/27/07: E&M visits on same day as allergy injection services for new and established patients clarified.
        • Initial committee approval and effective: 10/17/06
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        •  State Medicaid
        •  Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
        Related Material:
        None
             expand Obstetrical Services
        Effective Date:7/8/2009
        Policy:
        Amerigroup allows reimbursement for obstetrical services unless otherwise noted by provider, state, federal and CMS contracts or requirements.
        • Amerigroup does not provide additional reimbursement for multiple births (e.g., twins, triplets, etc.) by the same delivery method (e.g., vaginal or cesarean section).
        • Multiple surgery guidelines apply when the same physician or physician group provides obstetrical care for multiple births (e.g., twins, triplets, etc.) by both vaginal and cesarean delivery. Reimbursement is based on the delivery code only for the secondary procedure.
        • Multiple delivery claims submitted with Modifier 22 will not be considered for additional reimbursement.
        • If cesarean delivery is performed with an assistant surgeon, assistant surgeon rules and fee reductions apply (see Amerigroup Assistant at Surgery Policy).
        Exemptions:
        • Amerigroup Florida, Inc. allows reimbursement of multiple deliveries with a Modifier 22.
        • Effective 03/15/09, Amerigroup Community Care of New Mexico, Inc. requires receipt of an executed Confirmation/Release Statement and Informed Consent for reimbursement to a midwife for out-of-hospital birthing services.
        Policy History:
        • Review approved and effective 07/08/09: Benefit coverage and limits information removed; reference to use of informational Modifier TH removed (i.e., does not affect reimbursement); SC benefit exemption for services provided by OB/GYN and Maternal Fetal Medicine specialists removed; NM exemption for midwife requirements added; medical criteria references removed; Modifier 22: Increased Procedural Service and Professional Anesthesia Services added as Related Policies.
        • Regulatory Update effective 06/01/08: SC exemption added
        • Initial committee approval and effective 07/17/06
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Assistant at Surgery (Modifier 80/81/82/AS)
        • Modifier 22: Increased Procedural Service
        • Modifier Usage
        • Multiple and Bilateral Surgery Reimbursement
        • Professional Anesthesia Services
        Related Material:
        Precertification Look Up Tool (PLUTO)
         
        collapse Prevention
             expand Vaccines for Children (VFC) Program
        Effective Date:1/30/2009
        Policy:
        Amerigroup allows reimbursement for vaccinations provided by the Vaccines for Children (VFC) program for eligible members under the age of 19, unless provider, state, federal or CMS contracts or requirements indicate otherwise. Medicaid providers who immunize children shall participate in the VFC Program and comply with all of the reporting requirements and procedures for provider participants.

        Reimbursement is based on the fee schedule or contracted/negotiated rate of the vaccine administration up to maximum fee limits set by the Centers for Disease Control and Prevention (CDC) and applicable modifiers as listed in Exhibit A. Amerigroup does not reimburse providers for the vaccine serum as it is provided free-of-charge through the VFC Program.
         
        Although providers shall only be reimbursed for the administration of the vaccine, serum code(s) must be included on the claim to meet regulatory and Healthcare Effectiveness Data and Information Set (HEDIS®) reporting requirements that members are receiving the proper immunization(s). Claims submitted without applicable serum, administration, and modifier codes may be rejected and/or denied.

        Reimbursement of Office Visits

        Vaccine administrations are separately reimbursable expenses from well-child exams or office visits. When the vaccine administration is the only service performed, Amerigroup does not allow reimbursement for a minimal office visit (i.e., an office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician where the presenting problem(s) are usually minimal and typically five minutes are spent performing or supervising these services).

        Non-VFC Members/Vaccines

        For members not eligible or for vaccines not provided under the VFC Program, Amerigroup reimburses providers for the administration and serum based on the fee schedule or contracted/negotiated rate.

        Reimbursement during State Supply Shortages

        During documented supply shortages within applicable state VFC programs, Amerigroup will reimburse providers for serum(s) based on the fee schedule or contracted/negotiated rate and applicable modifiers as listed in Exhibit A. Health plans shall develop internal processes and procedures to track state VFC program and CDC information to monitor vaccine shortages.
        Exemptions:
        There are no exemptions to this policy
        Policy History:
        • Review approved 11/07/11 and effective 01/30/09: policy template updated; TX exemption removed
        • Review approved 07/31/09: TX exemption updated
        • Review approved 12/29/08 and effective 01/30/09: Minimal office visit clarified; TX exemption added
        • Review approved 12/01/08 and effective 01/30/09: Non-VFC Members/Vaccines section added; State Supply Shortages section updated; Background updated; Market VFC Requirements for Eligible Members added
        • Original approved and effective: 09/01/05
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        • Centers for Disease Control and Prevention
        • Social Security Act, Section 1928: Program for Distribution of Pediatric Vaccines
        • State VFC Programs
        Definitions:
        Related Policies:
        • Modifier Usage.
        Related Material:
        collapse Prosthetics & Orthotics
             expand Prosthetic and Orthotic Devices
        Effective Date:9/27/2010
        Policy:
        Amerigroup reimburses prosthetic and orthotic devices when provided as part of a physician’s services, ordered by a physician and used in accepted medical practice unless otherwise noted by provider, state, federal, or CMS contracts or requirements.
         
        Reimbursement is based on the applicable fee schedule or contracted/ negotiated rate for the prosthetic or orthotic device dispensed. The design, materials, measurements, fabrications, testing, fitting and training in the use of the device are included in the reimbursement of the device and are not separately reimbursable expenses.
         
        Reimbursement covers the following:
        • Design
        • Materials
        • Measurements
        • Fabrications
        • Testing
        • Fitting
        • Training in the use of the device

        These items are not separately reimbursable expenses.

        Reimbursement is allowed for repair of prosthetic and orthotic devices in the following instances:

        • When the devices are repaired to make them serviceable
        • When the devices are no longer covered under the supplier’s or manufacturer’s warranty

        You will be reimbursed up to the estimated expense for replacement of the devices.

        Reimbursement is allowed for replacement of prosthetic and orthotic devices due to:

        • A change in the patient’s condition
        • A substantial change in the patient’s growth and/or weight
        • Permanent and/or accidental damage
        • Irreparable wear in consideration of the reasonable useful lifetime of the device (not less than five years) based on when the equipment is delivered to the member

        Nonreimbursable

        Amerigroup does not allow reimbursement for prosthetics and orthotics under the following conditions:

        • Provision of a device that exceeds the benefit limit (unless authorized through medical necessity)
        • Enhancements or upgrades of a device (e.g., deluxe or luxury) for the convenience of the member or caregiver
        • Changes to the aesthetic appearance of a device for the preference of the member or caregiver
        • A device is considered experimental or investigational
        • Repair or replacement of a device as a result of abuse or neglect
        • Repair or replacement of a device during the warranty period
        • An orthotic device that is available without a prescription and not custom fitted for the member (over-the-counter)

        Dental prosthetics are considered for reimbursement through delegated agreements between applicable Amerigroup health plans and contracted dental vendors.

        Exemptions:
        Amerigroup Community Care of New Mexico, Inc. allows reimbursement for replacement of prosthetic and orthotic devices (limited to one item every three years) in compliance with the New Mexico Human Services Department Medical Assistance Division provider manuals.

         

        Policy History:
        • Review approved 09/24/12: Policy template updated; New Mexico exemption updated for clarity
        • Policy updated November 16, 2010: New Mexico exemption added; background section/policy template updated
        • Review approved September 27, 2010: examples removed; background and definitions sections updated; policy template updated
        • Review approved October 20, 2008: background section/policy template updated
        • Initial committee approval and effective: September 6, 2006
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:

        Prosthetic device: an artificial structural and functional replacement of:

        • A limb/appendage or internal organ
        • All or part of the function of a permanently inoperative or malfunctioning internal body organ

        Orthotic device: a brace with rigid metal or plastic stays applied to the body:

        • For support or immobilization of a body part
        • To correct or prevent deformity
        • To assist or restore function

        General Reimbursement Policy Definitions

        Related Policies:
        Reimbursement of Items under Warranty.
         
        Related Material:
        None
         
        collapse Radiology
             expand Multiple Radiology Payment Reduction
        Effective Date:4/9/2012
        Policy:
        Amerigroup allows reimbursement for multiple diagnostic imaging procedures, unless provider, state, federal, or CMS contracts or requirements indicate otherwise.
         
        Certain multiple diagnostic imaging procedures will be subject to a multiple Procedure Payment Reduction (MPPR) when services are performed by the same physician or health care professional with the same National Provider Identifier (NPI) on the same date of service during the same patient encounter.
         
        The global and Technical Component (TC) of certain diagnostic imaging procedures will reimburse at 100 percent of the physician fee schedule or negotiated amount for the service with the highest TC payment. Payment is made at 50 percent for the TC of subsequent services furnished by the same physician to the same patient in the same session on the same day.
         
        A reduced allowance for the second and subsequent procedures will not apply when multiple imaging procedures are billed appended with Modifier 59 to indicate the procedure was done on the same day but not during the same session.
         
        A single imaging procedure is subject to the multiple imaging reductions when submitted with multiple units.
        Exemptions:
        This policy is not applicable for the following markets:
        • Amerigroup Texas Inc. and Amerigroup Insurance Company
        • Amerigroup Florida Inc.
        • Amerigroup Maryland Inc.
        • Amerigroup Georgia Managed Care Company Inc.
        Policy History:
        Initial policy approved and effective 04/09/12
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        Related Policies:
        • Modifier Usage
        • Modifier 59 Distinct Procedural Service
        Related Material:
        None
             expand Portable/Mobile/Handheld Radiology Services
        Effective Date:4/11/2012
        Policy:
        Amerigroup allows reimbursement for portable/mobile radiology services when ordered by a physician and performed by qualified portable radiology suppliers unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

        Reimbursement is based on the applicable fee schedule or contracted/ negotiated rate for the radiological service, transportation and setup components with the use of applicable modifiers.

        [NOTE: Portable radiology suppliers must be licensed or registered to perform services as required by applicable state laws.]

        Transportation and Setup
         
        Amerigroup allows reimbursement for transportation and setup of portable radiology equipment to the member’s residence where the services are performed. Reimbursement for transportation is based on a single payment for each particular location regardless of the number of members receiving radiological services. For services provided to more than one member, the transportation cost is divided by the total number of members receiving services at that location. If more than one member receives portable radiology services, providers must bill with the following applicable modifiers:
        • Modifier UN – two members served
        • Modifier UP – three members served
        • Modifier UQ – four members served
        • Modifier UR – five members served
        • Modifier US – six or more members served
          • Total payment for the service is divided by six regardless of the number of members served
        • There is no modifier required when only one member is served

        Reimbursement for the setup cost of portable radiology equipment at the member’s residence where the services are performed is not separately reimbursable.

        Handheld Radiology

        The use of handheld radiology instruments is allowed. Reimbursement will be part of the physician’s professional service, and no additional charge will be paid. The technical components for handheld radiology are not separately reimbursable.

        Nonreimbursable

        Amerigroup does not allow reimbursement for transportation costs of equipment stored at any location qualifying as a member’s residence.

        Exemptions:
        Amerigroup New York, LLC allows reimbursement for both professional and technical components of handheld radiology procedures when the qualified physician performs service in his or her office and owns or directly leases the equipment.
         
        Policy History:
        • Review approved July 18, 2011, and effective April 11, 2012: Updated accountability language; handheld radiology language added; New York exemption added
        • Review approved October 11, 2010: updated to indicate setup is not separately reimbursable; removed Florida exemption; updated policy template and Background section
        • Review approved December 15, 2008, and effective February 13, 2008: Modifier usage for members served clarified; medical necessity criteria removed; Florida exemption added
        • Initial approval and effective December 6, 2006
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        Related Policies:
        Modifier Usage
         
        Related Material:
        None
         
        collapse Reimbursement Administration - General Information
             expand Claims Requiring Additional Documentation
        Effective Date:7/19/2010
        Policy:
        Professional providers and facilities are required to submit additional documentation for adjudication of applicable types of claims. If the required documentation is not submitted, the claim may be denied. Applicable types of claims include:
        • Claims with unlisted or miscellaneous codes
        • Claims for services requiring clinical review (e.g., complicated or unusual procedures, emergency room services)
        • Claims for services found to possibly conflict with covered benefits to covered persons after validity review of members’ medical records (e.g., member eligibility)
        • Claims for services found to possibly conflict with medical necessity of covered benefits to covered persons (e.g., new technology, potential experimental or investigational procedures or devices, potential cosmetic procedures)
        • Claims requesting an extension of benefits
        • Claims being reviewed for potential fraud, abuse or demonstrated patterns of billing/coding inconsistent with peer benchmarks
        • Claims for services that require an invoice (e.g., custom DME/prosthetics that are reimbursed based on purchase price)
        • Claims for services that require an itemized bill (e.g., stop loss, denied inpatient days, carve-out services)
        • Claims for beneficiaries with Other Health Insurance (OHI)
        • Claims requiring documentation of the receipt of an informed consent (e.g., sterilization, hysterectomy)
        • Claims requiring a Certificate of Medical Necessity (e.g., motorized wheelchairs, lymphedema pumps, oxygen)
        • Appealed claims where supporting documentation may be necessary for determination of payment
        • Other documentation required by the CMS and state or federal regulation
        Amerigroup may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations. If documentation is not provided following the request or notification, Amerigroup may:
        • Deny the claim, as provider failed to provide required prepayment documentation
        • Recoup monies previously paid on the claim, as provider failed to provide required documentation for post-payment review
        Amerigroup is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation.
        Exemptions:
        As of October 6, 2008, Amerigroup Ohio, Inc. allows facilities to bill certain surgical unlisted codes without documentation of a written description, office notes, or operative report describing the procedure or service performed and to be reimbursed based on a percentage determined by the state of Ohio or the provider’s contract. Amerigroup reserves the right to request medical records to support the claim. [NOTE: This exemption does not apply if the facility provides a description for the unlisted code and an established code exists to describe the service.]
        Policy History:
        • Review approved March 12, 2012, and effective July 19, 2010
        • Review approved February 14, 2011: Removed all references to AMISYS; Background section/policy template updated
        • Review approved and effective July 19, 2010: Payment recoupment added; inconsistent billing/coding patterns clarified; deleted examples in opening paragraph; subject to contractual obligation added; background section/policy template updated
        • Review approved June 1, 2009: List of claim types requiring additional documentation confirmed as all-inclusive
        • Review approved March 23, 2009: Documentation of invoices and itemized bills added, OH exemption added, and Background and Related Policies section/policy template updated.
        • Initial committee approval and effective June 16, 2006
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Claims Timely Filing
        • Unlisted or Miscellaneous Codes (Dump Codes)
        Related Material:
        None
         
             expand Claims Submission – Required Information for Facilities
        Effective Date:6/16/2006
        Policy:
        Institutional Providers (Facilities) are required, unless otherwise stipulated in their contract, to submit original Centers for Medicare & Medicaid Services UB-04/CMS-1450 Medicare Uniform Institutional Provider bills to us for payment of health care services. You must submit a properly completed UB-04/CMS-1450 for services performed or items/devices provided. If the required information is not provided, the claim is not considered a clean claim and we can delay or deny payment without being liable for interest or penalties. The UB-04/CMS-1450 claim form must include the following information, if applicable:
        • Facility information (i.e., name and address)
        • Bill type
        • Federal Tax Identification Number (TIN)
        • Date/period the UB-04/CMS-1450 covers
        • Patient information (i.e., name, Amerigroup or Amerivantage subscriber number, address, date of birth, gender, and marital status)
        • Admission date and type
        • Admission hour for inpatient services only
        • Point of origin for admission or visit
        • Discharge hour for inpatient services only
        • Patient discharge status code
        • Condition code(s)
        • Accident state, if applicable
        • Occurrence code(s) and date(s)
        • Occurrence span code(s) and date(s)
        • Revenue code(s) and description(s) and applicable corresponding CPT/HCPCS codes, if necessary. Applicable claims billed only with the revenue code will be denied. You will be asked to resubmit with the correct HCPCS/CPT code in conjunction with the applicable revenue code.
        • Date(s), unit(s) and total charge(s) of service(s) rendered
        • Insurance payer’s information (i.e., name, provider number and Coordination of Benefits (COB) secondary and tertiary payer information)
        • Prior payments – payers, if applicable
        • Insured’s information (i.e., name, relationship to patient, ID number, insurance group name and number, date of birth, employer name, and location)
        • Principal, admitting, and other ICD-9 Diagnosis codes, including 4th and 5th digit when required
        • Present On Admission (POA) indicator as applicable
        • Code (ICD-9 Procedure) and date of principal procedure for inpatient services, if applicable
        • National provider identifier (NPI) state Medicaid provider number (in accordance with the applicable state requirements)
        • Medicare provider number for Medicare Advantage claims (in accordance with CMS requirements)
        • Encounter reporting data elements in accordance with applicable state compliance requirements including:
          • Admission source code
          • Applicable value code for billed admission type code
          • Birth weight with applicable value and admission type codes
          • Facility type code
          • National Drug Code(s) (NDC) to include the NDC number, unit price, quantity and composite measure per drug
        We cannot accept claims with alterations to billing information (i.e., using correction fluid/tape, crossing out, or writing over mistakes). Claims that have been altered will be returned to you with an explanation of the reason for the return.
        Although we prefer the submission of claims electronically through the Electronic Data Interchange (EDI), we will accept paper claims. A paper claim must be submitted on an original claim form with dropout red ink, computer printed or typed, in a large, dark font in order to be read by Optical Character Reading (OCR) technology. All claims must be legible. If any field on the claim is illegible, the claim will be rejected or denied.
        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:
        • Review approved 11/05/12: policy template updated
        • Review approved 10/10/11, effective 06/16/06: updated template; removed link to CMS website and verbiage that the form is available at the CMS website, added claim form to CMS-1450 reference, included Amerivantage subscriber number, removed from the NPI language that states in accordance with dates set by applicable state, added “to include” language for National Drug Code, clarified language that claims will be “rejected or” denied; HCPCS/CPT language added.
        • Review approved 08/10/09: Forms names/NPI/provider number requirements updated, admission/discharge, point of origin, accident State, occurrence span, COB, and prior payments requirements clarified, POA Indicator requirement added, encounter data requirements clarified, acceptance of original claim forms clarified, denial of illegible claims added, and reference to handwritten claims removed
        • Initial committee approval and effective: 06/16/06
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        Related Policies:
        • Acceptance of Altered Claim Forms
        • Claims Requiring Additional Documentation
        • Claims Submission – Required Information for Professional Providers
        Related Material:
        Amerigroup Electronic Data Interchange Manual
             expand Claims Submission – Required Information for Professional Providers
        Effective Date:6/16/2006
        Policy:
        Professional providers of health care services are required, unless otherwise stipulated in their contract, to submit an original Centers for Medicare & Medicaid Services (CMS)-1500 Health Insurance Claim Form to us for payment of health care services.
         
        You must submit a properly completed CMS-1500 for services performed or items/devices provided. If the required information is not submitted, the claim is not considered a clean claim, and we will deny payment without being liable for interest or penalties. The CMS-1500 claim form must include the following information if applicable:
        • Patient information (i.e., name, address, date of birth, gender, status, relationship to insured and medical condition as related to employment or an accident)
        • Insured’s information (i.e., ID number, Amerigroup or Amerivantage subscriber number, name, address [including ZIP code], telephone, policy group or FECA number, date of birth, name of employer or school, name of insurance plan or program, and name of other health benefit plan)
        • Coordination of Benefits (COB)/other insured’s information (i.e., name, date of birth, policy or group number, name of employer or school, and name of insurance plan or program)
        • Name of referring physician or source
        • Indication of outside laboratory
        • ICD-9 Diagnosis code(s), including 4th and 5th digit when required
        • Date(s) of service(s) rendered
        • Place of service/location code(s)
        • Description of services rendered using CPT-4 codes/HCPCS codes and appropriate modifiers
        • Charge(s) for service(s) rendered
        • Day(s) or unit(s) related to service(s) rendered
        • Total charges, amount paid by patient (i.e., copay) and balance due
        • Federal Tax Identification Number (TIN)
        • Name and address of facility where services were rendered and the National Provider Identifier (NPI) of the service facility if applicable
        • National provider identifier
          • Individual servicing provider’s NPI must be reported as the Rendering Provider ID (if applicable)
          • When billing is from a group, the group’s NPI must be reported as the Billing Provider (if applicable)
        • Remittance information (i.e., name, address, telephone)
        • Indication of signature on file or a handwritten or computer generated signature for the provider of service or his or her representative, and date the form was signed
        • National Drug Code(s) to include the NDC number, unit price, quantity and composite measure per drug
        • State Medicaid provider number as required by state regulation (in accordance with the applicable State requirements)
        • Medicare provider number for Medicare Advantage claims (in accordance with CMS requirements)
        We cannot accept claims with alterations to billing information (e.g. using correction fluid/tape, crossing out, or writing over mistakes). Altered claims will be returned to you with an explanation of the reason for the return. Although we prefer the submission of claims electronically through the Electronic Data Interchange (EDI), we will accept paper claims. A paper claim must be submitted on an original claim form with dropout red ink, computer printed or typed, in a large, dark font in order to be read by Optical Character Reading technology. All claims must be legible. If any field on the claim is illegible, the claim will be rejected or denied.
        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:
        • Review approved 11/05/12: Background section/policy template updated
        • Review approved 10/10/11 effective 06/16/06: Added NPI language; Unless otherwise stipulated in the contract added; added claim form verbiage; removed link to CMS site within policy; added Amerivantage subscriber number; signature requirements; additional NDC requirements.
        • Review approved 08/10/09: NPI/provider number requirements updated, acceptance of original claim forms clarified, denial of illegible claims added, reference to handwritten claims and authorization information removed, and Background section/policy template updated.
        • Initial committee approval and effective: 06/16/06
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Acceptance of Altered Claim Forms
        • Claims Requiring Additional Documentation
        • Claims Submission – Required Information for Facilities
        Related Material:
        Amerigroup Electronic Data Interchange Manual
             expand Claims Timely Filing: Participating and Nonparticipating
        Effective Date:8/27/2012
        Policy:
        Amerigroup allows reimbursement of claims for covered services for covered members in compliance with federal and/or state mandates regarding Claims Timely Filing requirements (see Exhibit A). In the absence of such mandates, Amerigroup follows the standard of:
        • 90 days for participating providers and facilities.
        • 12 months for nonparticipating providers and facilities.

        Timely filing is determined by subtracting the date of service from the date Amerigroup receives the claim, and comparing the number of days to the applicable federal or state mandate. If there is no applicable federal or state mandate, then the number of days is compared to the Amerigroup standard. If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last day of service. Limits are based on calendar days unless otherwise specified. If the member has other health insurance that is primary, then timely filing is counted from the date of the Explanation of Payment (EOP) of the other carrier.

        Providers resubmitting claims for corrections must clearly mark the claim a Corrected Claim. Failure to mark the claim appropriately may result in denial of the claim as a duplicate. Corrected claims must be received within the applicable timely filing requirements of the originally submitted claim, due to the original claim not being considered a clean claim.

        Claims filed beyond federal- or state-mandated or Amerigroup standard timely filing limits will be denied as outside the timely filing limit. Services denied for failure to meet timely filing requirements are not subject to reimbursement unless the provider presents documentation proving a clean claim was filed within the applicable filing limit.

        Exemptions:
        • Amerigroup Texas, Inc. and Amerigroup Insurance Company allow 120 days from the original claim’s EOP date for all corrected claims and disputes.
        • Amerigroup Tennessee, Inc. allows corrected/or replacement claims to be submitted within 60 calendar days of the original claim’s EOP paid date or within 120 calendar days of the date of service, whichever is greater.
        • Amerigroup Community Care of New Mexico, Inc. waives timely filing of claims submitted by I.H.S. and Tribal 638 facilities in compliance with state guidance.
        • Amerigroup Georgia Managed Care Company, Inc. allows corrected claims to be submitted within 90 days from the date of the original claim submission.
        • Amerigroup reserves the right to waive timely filing requirements on a temporary basis following documented natural disasters or under applicable state guidance.
        Policy History:
        • Review approved 08/27/12: Exhibit A requirements added for Kansas.
        • Review approved 11/07/11 and effective 06/16/10: background and policy template updated; TX and TN exemptions added; FL, GA, NV, TN and TX requirements updated in Exhibit A.
        • Update due to regulatory directive (Committee Approval not required in accordance with Reimbursement Policy Program Guidelines, policy #05-017):
          • 06/16/10 to add NM exemption; removed SC from Exhibit A; Background section/policy template updated.
        • Review approved and effective 09/21/09: Market Timely Filing Requirements exhibit updated for FL, NJ, NM and OH; DC removed.
        • Review approved and effective 12/15/08: OHI information clarified; timely filing waiver/GA corrected claim exemptions added; contracting/appeals process exemptions removed; Market Timely Filing Requirements updated.
        • Update due to regulatory directive (Committee Approval not required in accordance with Reimbursement Policy Program Guidelines, policy #05-017):
          • 07/28/08 updated Market Timely Filing Requirements exhibit for GA Families per Chapter 200 of the Medicaid Policy & Procedure Manual
          • 03/26/09 updated Market Timely Filing Requirements exhibit for NY
        • Original approved and effective: 08/09/06
        Reference and Research Material:

        This policy was developed through consideration of the following:

        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Eligible Charges
        • Requirements for Documentation of Proof of Timely Filing
        Related Material:
             expand Code and Clinical Editing Guidelines
        Effective Date:7/12/2010
        Policy:

        Amerigroup applies Code and Clinical Editing Guidelines (CCEG) to evaluate claims for accuracy and adherence to accepted national industry standards and plan benefits, unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements.

        Amerigroup uses software products that ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices are followed. CCEG consists of the following measures including, but not limited to:

        • Code editing software, CMS National Correct Coding Initiative (NCCI) edits and Outpatient Code Edits (OCE)
        • Clinical criteria
        • Licensed clinical medical review
        • Claims processing platform

        Per state requirements, Amerigroup publishes its use of specific commercial code editing software. Amerigroup only customizes applicable CCEG measures due to compelling business reasons.

        CCEG measures are updated as applicable to incorporate new codes, code definition changes and to edit rule changes. All claims submitted after the configuration implementation date, regardless of service date, will be processed according to up-to-date CCEG measures. No retrospective payment changes, adjustments and/or requests for refunds will be made when processing changes result from new code editing rules within a module update. The member is not responsible and should not be balance billed for any procedure for which payment has been denied or reduced as a result of CCEG measures.

        Amerigroup uses CCEG to analyze outpatient services, including those that are considered:

        • Rebundled or unbundled services
        • Mutually exclusive services
        • Incidental procedures or items
        • Inappropriately billed visits
        • Diagnosis to procedure mismatch
        • Upcoded services

        Other procedures and categories that are reviewed include:

        • Cosmetic procedures
        • Obsolete or unlisted procedures
        • Age/gender mismatch procedures
        • Investigational or experimental procedures
        • Procedure eligibility (e.g., assistant at surgery, co-surgeons, surgical teams, multiple fee reductions, etc.)
        • Procedures billed with inappropriate modifiers

        Amerigroup does not allow reimbursement for services, procedures, items, etc. that conflict with CCEG.

        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:
        • Review approved 05/21/12: Policy template updated
        • Review approved and effective 07/12/10: Resources used to develop CCEG updated; timeline requirements for system updates deleted; services reviewed and analyzed clarified; policy template/Background updated
        • Initial committee approval 05/16/07 and effective 05/01/05: Policy adapted from:
          • Bundling Guidelines, #05-002, effective 05/01/05
          • ClaimCheck®, #05-003, effective 05/01/05
          • Consistency Guidelines, #05-005, effective 02/05
        Reference and Research Material:

        This policy was developed through consideration of the following:

        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Global Surgical Package
        • Supplies and Limits
        Related Material:

        None

             expand Documentation Standards for Episodes of Care
        Effective Date:12/7/2011
        Policy:
        Amerigroup requires that upon request for clinical documentation to support claims payment for services, the provided information should:
        • Identify the member
        • Be legible
        • Reflect all aspects of care

        To be considered complete, documentation for episodes of care will include, at a minimum, the following elements:

        • Patient identifying information
        • Consent forms
        • Health history, including applicable drug allergies
        • Physical examinations
        • Diagnoses and treatment plans for individual episodes of care
        • Physician orders
        • Face-to-face evaluations, when applicable
        • Progress notes
        • Referrals, when applicable
        • Consultation reports, when applicable
        • Laboratory reports, when applicable
        • Imaging reports (including X-ray), when applicable
        • Surgical reports, when applicable
        • Admission and discharge dates and instructions, when applicable
        • Preventive services provided or offered, appropriate to member’s age and health status
        • Evidence of coordination of care between primary and specialty physicians, when applicable

        Providers should refer to standard data elements to be included for specific episodes of care as established by The Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations. A single episode of care refers to continuous care or a series of intervals of brief separations from care to a member by a provider or facility for the same specific medical problem or condition.

        Documentation for all episodes of care must:

        • Be legible to someone other than the writer
        • Contain information identifying the member on each page in the medical record
        • Include the date and author identification, which may be a handwritten signature, unique electronic identifier or initials for each entry in the medical record

        Other Documentation Not Directly Related to the Member

        Other documentation not directly related to the member, but relevant to support clinical practice, may be used to support documentation regarding episodes of care, including:

        • Policies, procedures and protocols
        • Critical incident/occupational health and safety reports
        • Statistical and research data
        • Clinical assessments
        • Published reports/data

        Amerigroup may request that providers submit additional documentation, including medical records or other documentation not directly related to the member, to support claims submitted by the provider. If documentation is not provided following the request or notification or if documentation does not support the services billed for the episode of care, Amerigroup may:

        • Deny the claim
        • Recover and/or recoup monies previously paid on the claim

        Amerigroup is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation.

        Exemptions:
        There are no exemptions to this policy.
        Policy History:
        • Initial committee approval 06/06/11 and effective 12/07/2011
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • The Joint Commission Standards
        Definitions:
        Related Policies:
        • Claims Requiring Additional Documentation
        Related Material:
        None
             expand Duplicate or Subsequent Services on the Same Date of Service
        Effective Date:10/20/2008
        Policy:

        Amerigroup allows reimbursement of a duplicate or subsequent service provided on the same date of service if billed with an appropriate modifier or with additional units, as applicable within benefit limits, unless otherwise noted by provider, state, federal or CMS contracts or requirements.

        Reimbursement of a Duplicate or Subsequent Service

        Amerigroup will deny a duplicate or subsequent service provided on the same date of service billed on the same or separate claims unless billed with an applicable modifier. The modifiers below indicate the service was appropriately repeated or additionally billed for the same member:

        • Modifier 62: Co-Surgeons
        • Modifier 66: Surgical Teams
        • Modifier 76: Repeat Procedure by the Same Physician
        • Modifier 77: Repeat Procedure by Another Physician
        • Modifier 80: Assistant at Surgery providing full assistance to the primary surgeon
        • Modifier 81: Assistant at Surgery providing minimal assistance to the primary surgeon
        • Modifier 82: Assistant at Surgery, when a qualified resident surgeon is not available to assist the primary surgeon
        • Modifier AS: Assistant at Surgery who is a nonphysician (e.g. physician assistant, nurse practitioner)
        • Modifier 91: Repeat Clinical Diagnostic Laboratory Test
        • Modifier GG: Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
        • Modifier GH: Diagnostic mammogram converted from screening mammogram on same day

        Amerigroup will review claims billed with suspected duplicate or subsequent services. Claims will be denied for services determined to be duplicate or subsequent claims without the appropriate modifier.

        Reimbursement of Bundled Services

        When a service is unbundled from a more complex or comprehensive service and billed individually on the same date of service as the more comprehensive service:

        • The claim line for the individual service will be denied through code editing if billed on the same claim
        • The claim will be reviewed if billed on separate claims

        The following modifiers indicate an individual service is distinct and separate from the more comprehensive 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 59: Distinct Procedural Service
        Exemptions:
        • Amerigroup Community Care of New Mexico, Inc. allows reimbursement of claims submitted by I.H.S. providers for duplicate or subsequent services on the same date of service without use of modifiers in compliance with state guidelines.
        • Amerigroup Washington, Inc. does not allow reimbursement of duplicate services for occupational, physical and speech therapy when both providers are performing the same or similar procedure(s), in compliance with state guidelines.
        • Refer to specific modifier policies for applicability to individual states.
        Policy History:
        • Review approved December 6, 2010: policy reorganized for clarity; assistant at surgery modifiers added; processes and benefit limits removed; assistant at surgery modifiers and policy reference added; general exemption added; NM exemption added; Definitions and Background sections, policy template updated
        • Review approved October 20, 2008: Subsequent services clarified, bundled services section added and Background section/policy template updated
        • Initial committee approval and effective: June 16, 2006
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:

        Duplicate Services

        A service is considered a definite or possible duplicate if some or all of the following elements on the claim match:

        • Member
        • Date of service
        • Charge amount
        • Provider of service
        • Type of service, based on procedure or revenue codes used

        A service is suspected duplicate if the following elements on the claim match:

        • Member
        • Procedure code
        • Date of service

        Subsequent service: for purposes of this policy, a medically necessary service that is performed or provided for the same member more than once on the same date of service.

        General Reimbursement Policy Definitions

        Related Policies:
        • Assistant at Surgery (Modifiers 80/81/82/AS)
        • Code and Clinical Editing Guidelines
        • Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
        • Modifier 59: Distinct Procedural Service
        • Modifier 62: Co-Surgeons
        • Modifier 66: Surgical Teams
        • Modifier 76: Repeat Procedure by the Same Physician
        • Modifier 77: Repeat Procedure by Another Physician
        • Modifier 91: Repeat Clinical Diagnostic Laboratory Test
        • Modifier Usage
        Related Material:
        None
         
             expand Eligible Charges
        Effective Date:4/1/2010
        Policy:

        Amerigroup allows reimbursement of eligible charges unless provider, state, federal, or CMS contracts or requirements indicate otherwise.   Eligible charges are those charges billed by the provider subject to conditions and requirements which make the service eligible for reimbursement.

        Eligibility for reimbursement of the service is dependent upon application of the following conditions and requirements:

        • Member program eligibility
        • Provider program eligibility
        • Benefit coverage
        • Authorization requirements
        • Provider manual guidelines
        • Amerigroup administrative policies
        • Amerigroup clinical policies
        • Amerigroup reimbursement policies
        • Code editing logic

        The allowed amount reimbursed for the eligible charge is based on the applicable fee schedule or contracted/negotiated rate after application of coinsurance, copayments, deductibles and coordination of benefits.

        Amerigroup will not reimburse providers for:

        • Items the provider receives free of charge
        • Items the provider provides to the member free of charge

        In absence of clear language or specific reference to eligible charges in provider contracts, the use of the following terms will default to eligible charges as stated within this policy:

        • “Billed charges”
        • “Covered charges”
        • “Billed charges for covered services”
        • “Allowed charges”
        • “Percent of charge"
        Exemptions:

        There are no exemptions to this policy.

        Policy History:
        • Review approved 04/09/12 and effective 04/01/10: Background section/Policy template updated
        • Review approved 04/11/11 and effective 04/01/10: Background section and policy template updated
        • Review approved 11/02/09 and effective 04/01/10: Allowed amount and default terms for eligible charges clarified, nonreimbursement for items free of charge added, Background section/policy template updated
        • Review approved and effective 02/27/07: No changes from original policy
        • Initial committee approval and effective 03/02/06
        Reference and Research Material:
        This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status, in addition to the following:
        • CMS
        • State Medicaid
        •  Amerigroup state contracts
        • National Association of Insurance Commissioners (NAIC) Model Regulation, 2005
        Definitions:
        Related Policies:
        • Eligible Charges Processing Instruction
        Related Material:
        None
             expand Emergency Services: Nonparticipating Providers and Facilities
        Effective Date:8/27/2012
        Policy:
        Amerigroup allows reimbursement for emergency services provided by nonparticipating providers and facilities unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Unless otherwise required by federal and/or state regulation or contract, reimbursement is based on no more than:
        • For Medicaid product lines only, the amount that would have been reimbursed to the provider by the beneficiary’s state Fee-For-Service (FFS) Medicaid program
        • For Medicare product lines only, the amount that would have been reimbursed to the provider if the beneficiary were enrolled in original Medicare
        • For all other product lines, the applicable out-of-network emergency rate for nonparticipating providers and facilities

        Amerigroup adheres to the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) and the federal Medicaid managed care regulations.

        Amerigroup will act in accordance with the Deficit Reduction Act (DRA) of 2005, Section 6085, with an effective date of January 1, 2007, that states:

        “Any provider of emergency services that does not have in effect a contract with a Medicaid managed care entity that establishes payment amounts for services furnished to a beneficiary enrolled in the entity’s Medicaid managed care plan must accept as payment in full no more than the amounts (less any payments for indirect costs of medical education and direct costs of graduate medical education) that it could collect if the beneficiary received medical assistance under this title other than through enrollment in such an entity. In a state where rates paid to hospitals under the state plan are negotiated by contract and not publicly released, the payment amount applicable under this subparagraph shall be the average contract rate that would apply under the state plan for general acute care hospitals or the average contract rate that would apply under such plan for tertiary hospitals.”

        Amerigroup shall develop and maintain a record, pursuant to DRA stipulations, for:

        • Each market’s payment methodology according to the respective state’s FFS Medicaid program (e.g., reimburses noncontracted out of state providers and facilities at the host state’s rates versus their in-state rate)—see Exhibit A
        • DRA applicability to each market’s product lines—see Exhibit B

        Amerigroup will not limit consideration of reimbursement for emergency services on the basis of lists of diagnoses or symptoms; however, additional medical record documentation may be required in order to clearly identify and determine appropriate reimbursement of emergency services.

        Claims for emergency services are subject to the Amerigroup Eligible Charges, Code and Clinical Editing, and Claims Requiring Additional Documentation policies.

        Exemptions:
        • Amerigroup New Jersey, Inc., in accordance with New Jersey state regulations will reimburse nonparticipating in-state hospitals at 95 percent of the Medicaid FFS.
        • Amerigroup Texas, Inc. and Amerigroup Insurance Company nonparticipating facility claims for emergency services are sent to the state Medicaid administrator for ACSTM pricing to ensure such facility claims are reimbursed in accordance to the Deficit Reduction Act of 2005 Sec. 6085.
        • Amerigroup Maryland, Inc. allows reimbursement to a network group at the participating provider rate for covered services provided by a nonparticipating provider if all of the following conditions apply:
          • The provider is employed by or is a member of the group
          • The provider has applied for acceptance into the Amerigroup Maryland, Inc. network and has been notified by Amerigroup of its intent to continue processing the credentialing application
          • The provider has a valid license to practice in the state of Maryland
          • The provider is currently credentialed by an accredited hospital in the state of Maryland or has professional liability insurance

        [NOTE: If the provider’s application is rejected, Amerigroup Maryland, Inc. will reimburse according to policy for covered services provided on or after the date of the rejection notice.]

        Policy History:
        • Effective 05/30/13: VA removed from Exhibit A
        • Policy template updated with NJ exemption 01/23/13; disclaimer template updated 7/17/13
        • Review approved and effective 08/27/2012: Related Materials section updated; Kansas, Washington, and Louisiana added to Exhibits A and B.
        • Review approved August 15, 2011: Texas exemption language updated; South Carolina exemption removed
        • Review approved August 10, 2009, and effective October 9, 2009: Host state versus in-state reimbursement and DRA applicability clarified; related material exhibits and Maryland exemption added; Background section and policy template updated
        • Initial committee approval and effective date: September 20, 2006
        Reference and Research Material:
        This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status, in addition to the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • Deficit Reduction Act of 2005 (Pub.L. No. 109-171)
        • Emergency Medical Treatment and Labor Act (EMTALA)
        Definitions:
        Related Policies:
        • Claims Requiring Additional Documentation
        • Code and Clinical Editing
        • Eligible Charges
        Related Material:
             expand Locum Tenens Physicians
        Effective Date:8/23/2006
        Policy:

        We allow reimbursement of locum tenens physicians in accordance with the CMS guidelines unless provider, state or federal contracts or requirements indicate otherwise.

        We will reimburse the member’s regular physician or medical group for all services (including emergency visits) provided by a locum tenens physician during the absence of the regular physician in cases where the regular physician pays the locum tenens physician on a per diem or similar fee-for-time basis.

        Reimbursement to the regular physician or medical group is based on the applicable fee schedule or contracted/negotiated rate. The locum tenens physician may not provide services to a member for longer than a period of sixty (60) continuous days.

        A member’s regular physician or medical group should bill the appropriate procedure code(s), identifying the service(s) provided by the locum tenens physician with a Modifier Q6 appended to each procedure code.

        Exemptions:
        • Amerigroup Kansas, Inc. allows Locum Tenens reimbursement for a period of one year in accordance with Kansas Medical Assistance Program (KMAP).
        • Amerigroup Washington, Inc. allows Locum Tenens reimbursement for a period of 90 consecutive days in accordance with Washington State Health Care Authority (HCA) Physician-Related Services Manual. .
        Policy History:
        • Review approved 11/21/11: background section/policy template updated
        • Review approved 02/14/11: Exemption removed; Background section/policy template updated
        • Review approved 12/24/08: Background section/policy template updated
        • Initial committee approval and effective 08/23/06
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        Related Policies:

        Modifier Usage

         

        Related Material:
        None
         
             expand Medical Recalls
        Effective Date:10/17/2006
        Policy:

        Amerigroup does not allow reimbursement for repair, replacement, or procedures associated with items due to a medical recall unless provider, state, federal or CMS contracts or requirements indicate otherwise. The following are applicable items and procedures:

        • Durable medical equipment
        • Supplies
        • Prosthetics
        • Orthotics
        • Drugs/vaccines
        • Removal of a defective implanted device
        • Insertion of a replacement device
        • Complications associated with or caused by a defective device or drug/vaccine
        • Complications associated with or caused by insertion of a replacement device

        Amerigroup will:

        • Participate and provide any applicable documentation required in any applicable class action law suits due to a medical recall
        • Supply providers with medical recall information for dissemination to applicable members

        In circumstances where Amerigroup has reimbursed the provider for repair, replacement or procedures associated with items due to a medical recall, Amerigroup is entitled to recoup or recover fees from the manufacturer and/or distributor, as applicable.

        In applicable circumstances, providers should bill the appropriate condition and/or diagnosis code to identify a medically recalled item.

        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:
        • Review approved 11/07/11 and effective 10/17/06: Background section/policy template updated recovery language added.
        • Review approved 08/30/10: Background section/policy template updated.
        • Review approved 10/06/08: Background section/policy template updated.
        • Initial committee approval and effective: 10/17/06
        Reference and Research Material:

        This policy has been developed through consideration of the following:

        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:

        None

        Related Material:

        None

             expand Other Provider Preventable Conditions (OPPC)
        Effective Date:3/14/2013
        Policy:
        Amerigroup does not reimburse for Other Provider Preventable Conditions (OPPC) as identified by the CMS contracts and/or requirements.
         
        OPPCs are defined and categorized as:
        • Surgical or invasive procedure on the wrong body part
          • Modifiers: PA
          • ICD-9 Diagnosis: E876.7
          • Surgical Error Codes: MZ
        • Surgical or invasive procedure on the wrong patient
          • Modifiers: PB
          • ICD-9 Diagnosis: E876.6
          • Surgical Error Codes: MY
        • Wrong surgery or invasive procedure on patient
          • Modifiers: PC
          • ICD-9 Diagnosis: E876.5
          • Surgical Error Codes: MX
         
        Erroneous surgical events occurring during an inpatient stay should be reflected on Type of Bill 0110 (no-pay claim) along with all services or procedures related to the surgery. All other inpatient procedures and services should be submitted on a separate claim.
         
        NOTE: The PC modifier is defined as “Wrong Surgery on a Patient.” It should not be used to represent the professional component of a service. Claims that incorrectly use this modifier may be denied. Claims with this modifier used incorrectly must be resubmitted as a corrected claim and indicate the appropriate coding for the service(s) rendered.
         
        Procedures identified as OPPCs will be rejected or denied.
        Exemptions:
        Amerigroup Community Care of New Mexico, Inc. allows reimbursement for OPPCs when Medicaid is the secondary payer and/or the rendering provider is an Indian Health Service (IHS) or Tribal 638 facility in accordance with the State of New Mexico Human Services Department.
        Policy History:
        Initial committee approval 09/24/12 and effective 03/14/13.
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        Related Policies:
        • Claims Requiring Additional Documentation
        • Claims Submission – Required Information for Facilities
        • Claims Submission – Required Information for Professional Provider
        • Documentation Standards for Episodes of Care
        • Global Surgical Package
        • Present on Admission Indicator for Health-Care Acquired Conditions
        Related Material:
        None
             expand Present on Admission Indicator for Health-Care Acquired Conditions
        Effective Date:6/1/2012
        Policy:
        Amerigroup requires the identification of hospital-acquired conditions and health care-acquired conditions (both referred to in this document as Health Care-Acquired Conditions [HCAC]) through the submission of a Present On Admission (POA) indicator for all diagnoses on all facility claims unless otherwise noted by CMS.

        In accordance with the Deficit Reduction Act of 2005, POA indicators (see Exhibit A) are required for all inpatient discharges on or after October 1, 2007. The POA indicator is required for all primary and secondary diagnosis codes but is not required on the admitting diagnosis. Failure to include the POA indicator with the primary and secondary diagnosis codes may result in the claim being denied or rejected.

        If the POA indicator identifies an HCAC, the reimbursement for that episode of care may be reduced or denied. Amerigroup will not apply payment reduction if a condition defined as HCAC for a particular patient existed prior to the initiation of treatment for that patient by that provider.

        Unless noted in Exhibit B, this requirement applies to all facilities.

        If an HCAC is caused by one provider or facility (primary) payment will not be denied to the secondary provider or facility that treated the HCAC.

        Amerigroup reserves the right to request additional records to support documentation submitted for reimbursement.

        [Note: Claims may be subject to clinical review for appropriate reimbursement consideration.]

        Exemptions:
        Amerigroup Community Care of New Mexico, Inc. will not reduce or deny reimbursement when the POA indicator identifies an HCAC if Medicaid is the secondary payer and/or the rendering provider is an Indian Health Service (IHS) or Tribal 638 facility in accordance with the state of New Mexico Human Services Department.
        Policy History:
        • Update due to regulatory directive 09/07/12 (Committee Approval not required in accordance with Reimbursement Policy Program Guidelines, policy #05-017); New Mexico exemption.
        • Initial committee approval 03/12/12, and effective 06/01/12
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        Related Policies:
        • Claims Requiring Additional Documentation
        • Claims Submission – Required Information for Facilities
        • Claims Submission – Required Information for Professional Provider
        • Documentation Standards for Episodes of Care
        • Global Surgical Package
        Related Material:
             expand Reimbursement by Single Case Agreement with Nonparticipating Providers
        Effective Date:1/31/2009
        Policy:
        Amerigroup allows reimbursement to a nonparticipating provider (e.g., professional provider and/or facility) through a Single Case Agreement (SCA) for services provided to an Amerigroup member within a single episode of care, unless otherwise noted by provider, state, federal contracts or requirements.
        • Reimbursement for services through a SCA is based on a negotiated rate between the nonparticipating provider and the Health Plan to which the member belongs.

        Single Case Agreement Requirements

        • SCAs must provide a detailed description of the services to be rendered and the payment terms.
        • Physicians must have current licensure sufficient to support the specific services being requested, must not be under Office of Inspector General (OIG) sanction or excluded under the General Services Administration listing (GSA) and must meet their respective State requirements. Any physician found to have deficiencies as to their licensure, OIG/GSA standing and/or state standing will be refused authorization to provide care for a member until the deficiency is resolved to Amerigroup satisfaction.
        • If services are authorized, providers must sign and return the SCA prior to services being rendered.
        • If the provider renders authorized services, but does not sign and return the SCA, payment terms shall default to the applicable Health Plan’s out-of-network payment methodology.
        • A provider may appeal the claim to receive the negotiated payment terms by submitting the signed SCA with the appeal.
        • Amerigroup will not be responsible for interest payments in relation to a SCA that is not signed and returned by the provider.
        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:
        • Review approved 01/26/09: Reference to participating providers removed
        • Review approved 12/15/08 and effective 01/31/09: Extension of effective date
        • Initial committee approval 09/22/08 and effective 12/21/09: Policy adapted from Provider Relations/Provider Contracting Policy and Procedure: Single Case Reimbursement with Noncontracted Providers 01/01/02
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • Amerigroup State Contracts 
        • CMS State Medicaid Director Letter #08-003: Medicaid Integrity Excluded Providers, 12 July 2008
        • Social Security Act Title IX, Section 1128: Exclusion of Certain Individuals and Entities from Participation in Medicare and State Health Care Programs
        • Social Security Act Title IX, Section 1156: Obligations of Health Care Practitioners and Providers of Health Care Services; Sanctions and Penalties; Hearings and Review
        Definitions:
        • Single Case Agreement – an agreement executed with an out-of-network provider for a single episode of care to render specific services to a particular member when there is not an available participating provider to treat a particular member within the applicable State-required geographic access standard area, a particular member requires specific services that are not available through a participating provider or to maintain continuity of care with out-of-network provider.
        • Single Episode of Care – continuous care or a series of intervals of brief separations from care to a member by a provider or facility for the same specific medical problem or condition.
        • General Reimbursement Policy Definitions
        Related Policies:
        • Claims Submissions – Required Information for Professional Providers
        • Claims Submissions – Required Information for Facilities
        • Claims Timely Filing
        • Eligible Charges
        Related Material:
        • Precertification Look Up Tool (PLUTO)
        • Single Case Agreement Form (provided through Health Plan)
             expand Reimbursement for Items under Warranty
        Effective Date:10/17/2006
        Policy:
        Amerigroup does not allow reimbursement for repair or replacement of rented or purchased items during the warranty period designated by the applicable manufacturer unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements.
        Items include:
        • Durable medical equipment
        • Supplies
        • Prosthetics
        • Orthotics
        The manufacturer and/or distributor is responsible for:
        • Repairing the item or providing an acceptable replacement item
        • All fees associated with shipment of the defective item
        • All fees associated with delivery of the repaired item
        In circumstances where Amerigroup has reimbursed the provider for repair or replacement of an item during the warranty period, we are entitled to recoup fees from the manufacturer and/or distributor holding the warranty.
        Providers are required to supply members with information concerning the manufacturer’s warranty for all items dispensed to members.
        Exemptions:
        • Amerigroup will consider (after review) reimbursement for replacement of the item through another manufacturer only in circumstances where both the member and member’s provider deem the manufacturer’s replacement of the applicable item unacceptable. The design, materials, measurements, fabrications, testing, fitting and training in the use of another manufacturer’s replacement item are included in the reimbursement of the item and are not separately reimbursable expenses.
        • If the manufacturer offers an acceptable reduced price replacement but either the member prefers another replacement at full price or a provider did not utilize the reduced-price offer, Amerigroup allows reimbursement only up to the cost of the reduced price item under the prudent buyer rule.
        • If the manufacturer offers an acceptable replacement, but imposes a charge or pro rata payment, Amerigroup allows reimbursement for the partial payment imposed by the manufacturer subject to approval.
        Policy History:
        • Review approved 09/24/12: Background section/policy template updated.
        • Review approved September 24, 2010: Background section/policy template updated.
        • Review approved November 10, 2008: Background section/policy template updated.
        • Initial committee approval and effective October 17, 2006
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        • American Medical Association
        Definitions:
        Related Policies:
        None
         
        Related Material:
        None
         
             expand Reimbursement of Claims with Charge Discrepancies
        Effective Date:1/30/2007
        Policy:
        We allow reimbursement for claims submitted with an itemized statement where there is a discrepancy in total charges less than $100 unless provider, state, federal or CMS contracts or requirements indicate otherwise.
         
        Itemized claims with discrepancies totaling more than $100, or claims submitted that are not itemized and contain a discrepancy between the line item and the total amount billed will be denied and returned to the you as an unclean claim. You will be required to resubmit a corrected claim for reimbursement.
        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:
        • Review approved 10/08/12: Background section/policy template updated
        • Review approved 06/20/11: Clarification nonitemized claims; Background and Related Policies updated; policy language updated
        • Review approved 10/25/10:  Background section/policy template updated
        • Review approved 11/10/08:  Background section/policy template updated
        • Initial committee approval and effective 01/30/07
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • American Medical Association
        • State boards specific to policy subject
        Definitions:
        Related Policies:
        Claims Timely Filing: Participating and Non-Participating
         
        Related Material:
        None
             expand Reimbursement of Sanctioned and Opt-Out Providers
        Effective Date:12/9/2012
        Policy:
        Amerigroup does not allow reimbursement to providers who are excluded or debarred or opt-out from participation in state and federal health care programs Services rendered by a provider who is sanctioned or has opted out of participation in Medicare may only be reimbursed in urgent or emergent situations. Claims received for services other than emergency services submitted by sanctioned or opt-out providers will be denied.
        Amerigroup will allow reimbursement to a sanctioned or opt-out provider for emergency items or services only if the provider does not typically routinely provide emergency services, and the claim is accompanied by a sworn statement of the person furnishing the items or services specifying:
        • The nature of the emergency
        • The reason the items or services could not have been furnished by a provider eligible to furnish or order such items or services
        Note: Note: Payment may not be made for services furnished by an opt-out physician or practitioner who has signed a private contract with a Medicare beneficiary for emergency or urgent care items.
         
        Amerigroup screens all providers through state and federal exclusion lists.
        Exemptions:
        • Modifier GJ is required on Medicare claims for emergency or urgent care services when rendered by a sanctioned or opt out provider.
        • Amerigroup Texas Inc. and Amerigroup Insurance Company require all Medicaid providers to be listed on the state Medicaid master file in order to be reimbursed for services.
        Policy History:
        • Review Approved 05/21/12 and effective 12/09/12: opt-out language added; Texas exemption added; Medicare exemption added; Policy template updated
        • Original approved and effective 10/11/10
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • Code of Federal Regulations
        • Social Security Act
        Definitions:
        Related Policies:
        • Claims Requiring Additional Documentation
        • Reimbursement by Single Case Agreement with Nonparticipating Providers
        Related Material:
        None
         
             expand Requirements for Documentation of Proof of Timely Filing
        Effective Date:11/15/2006
        Policy:
        Amerigroup will reconsider reimbursement of a claim that is denied for failure to meet timely filing requirements, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, when a provider can:
        • Provide a date of claim receipt compliant with applicable timely filing requirements
        • Demonstrate good cause exists

        Documentation of Claim Receipt

        The following information will be considered proof that the claim was received timely. If the claim is submitted:

        • By U.S. mail — First class, return receipt requested or by overnight delivery service, the provider must provide a copy of the claim log that identifies each claim included in the submission
        • Electronically — The provider must provide the clearinghouse-assigned receipt date from the reconciliation reports
        • By fax — The provider must provide proof of facsimile transmission
        • By hand delivery — The provider must provide a claim log that identifies each claim included in the delivery and a copy of the signed receipt acknowledging the hand delivery

        The claims log maintained by providers must include the following information:

        • Name of claimant
        • Address of claimant
        • Telephone number of claimant
        • Claimant's federal tax ID number
        • Name of addressee
        • Name of carrier
        • Designated address
        • Date of mailing or hand delivery
        • Subscriber name
        • Subscriber ID number
        • Patient name
        • Date(s) of service/occurrence, total charge and delivery method

        Good Cause

        Good cause may be established by the following:

        • If the claim includes an explanation for the delay (or other evidence that establishes the reason), Amerigroup will determine good cause based primarily on that statement or evidence; and/or if the evidence leads to doubt about the validity of the statement, Amerigroup will contact the provider for clarification or additional information necessary to make a good cause determination.
        Exemptions:
        Amerigroup Georgia Managed Care Company Inc., Amerigroup New York, LLC, Amerigroup Insurance Company, and Amerigroup Texas Inc. shall process a provider’s claim without denying for failure to timely file if the provider files, in error, with another care management organization plan or with the state. The provider must send documentation/proof of filing [e.g., denial or Explanation of Payment (EOP)] that verifies the claim was initially submitted within the required timely filing period.
        Policy History:
        • Review approved 11/07/11 and effective 11/15/06: Background section/policy template updated
        • Review approved 09/21/09: Background section/policy template updated
        • Initial committee approval and effective: 11/15/06
        Reference and Research Material:
        This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice and review of medical literature and government approval status, in addition to the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        Definitions:
        Related Policies:
        • Claims Timely Filing: Participating and Nonparticipating
        • Date of Claim Receipt and Rebuttal Presumption – TX
        • Acknowledgement of Receipt and Received Date for EDI Submission
        Related Material:
        None
             expand Scope of Practice
        Effective Date:3/25/2013
        Policy:
        Amerigroup allows reimbursement for services that are within the provider’s scope of practice under state law in accordance with CMS guidelines unless provider, state, federal, or CMS contracts or requirements indicate otherwise.
         
        The provider shall be licensed in or hold a license recognized in the jurisdiction where the patient encounter occurs. Amerigroup allows reimbursement for Telemedicine performed within the provider’s scope of practice as regulated by state law.
        Scope of Practice is determined by:
        • Advanced practice education in a role and specialty
        • Legal implications
        • Scope of practice statements as published by national professional specialty and advanced organizations
        • State Medical Licensure requirements
        • Federal regulations
        Services provided outside of a practitioner’s scope of practice are not covered or reimbursable.
         
        Amerigroup allows reimbursement for providers with nonresidency but who have advanced training performing services in a Medically Underserved Area (MUA) as allowed by state law.
         
        Amerigroup allows reimbursement for providers when no board-certified physicians are available to meet local requirements.
        Exemptions:
        • Amerigroup Nevada Inc. allows reimbursement of Qualified Mental Health Associates (QMHA) when operating within the scope of practice of a licensed Clinical Supervisor.
        • Nonparticipating Medicare providers will be reimbursed according to CMS guidelines.
        Policy History:
        • Review approved 03/25/13; NV exemption added 04/16/2013; template updated 07/17/13
        • Initial committee approval 06/18/12 and effective 12/09/12
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • 42 CFR §440.2 – Federal Regulations on Scope of Practice
        Definitions:
        Related Policies:
        • Locum Tenens Physicians
        • Reimbursement of Sanctioned and Opt-Out Providers
        • Telemedicine/Telehealth
        Related Material:
        None
             expand Site of Service Payment Differential – Professional
        Effective Date:12/6/2006
        Policy:
        Amerigroup allows reimbursement for professional services performed in both facility and non-facility settings, unless provider, state, federal or CMS contracts or requirements indicate otherwise. Reimbursement is based on one of the following:
        • The applicable fee schedule or contracted/negotiated rate in line with the state or provider contract, which may include a site of service differential
        • The applicable out-of-network reimbursement rate for onparticipating providers
        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:
        • Review approved March 26, 2012: Background section/policy template updated
        • Review approved February 28, 2011: minor changes to language for ease of understanding; removed example lists; removed therapy procedures from non-facility definition; updated template, Background/Definitions sections
        • Review approved December 24, 2008: Background section/policy template updated
        • Initial committee approval and effective: December 6, 2006
        Reference and Research Material:

        This policy has been developed through consideration of the following:

        • CMS
        • State Medicaid
        • Amerigroup state contracts
        Definitions:
        • Site of Service Differential: Some professional services may be provided in either a facility or a non-facility. When a professional service is provided in a facility, the costs of the clinical personnel, equipment and supplies are incurred by the facility, not the physician practice. For this reason, reimbursement for professional services provided in a facility may be lower than if the services were performed in a non-facility setting. This difference in reimbursement, based on where the professional service is performed, is often referred to as a “site of service differential.”
        • Facility Rate: the rate paid for professional services performed in a facility setting
        • Non-facility Rate: the rate paid for professional services performed in a setting that is not a facility
        • Reimbursement Policy Definitions
        Related Policies:
        None
         
        Related Material:
        None
         
        collapse Surgery
             expand Abortion (Termination of Pregnancy)
        Effective Date:7/8/2009
        Policy:
        Amerigroup allows reimbursement of abortions unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate only when the applicable state abortion certification form is submitted with the claim. The completed and signed form certifies:
        • The pregnancy is the result of an act of rape or incest
        • The woman suffers from a physical disorder, injury or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed

        NOTE: An incomplete abortion, missed abortion, septic abortion, spontaneous abortion, stillbirth or threatened abortion is not considered an elective abortion.

        Exemptions:
        • Amerigroup Maryland, Inc. allows reimbursement of elective abortion when certified by the physician performing the procedure with the following additional criteria:
          • A substantial risk that continuation of the pregnancy could have a serious and adverse effect on the woman's present or future physical health
          • Continuation of the pregnancy is creating a serious effect on the woman's present mental health and if carried to term, there is substantial risk of a serious or long lasting effect on the woman's future mental health
          • The fetus is affected by genetic defect, serious deformity or abnormality
        • Effective August 13, 2010, Amerigroup Community Care of New Mexico, Inc. does not require an Abortion Certification Form to be submitted from any provider; however, claims submitted for elective abortion require medical director review.

        Effective January 1, 2007, Amerigroup New York, LLC does not require an Abortion Certification Form to be submitted from any provider, although claims from nonparticipating providers will be reviewed to ensure receipt of pertinent information to process the claim.

        Policy History:
        • Update approved July 18, 2011, and effective July 8, 2009: Accountability language updated and Maryland exemption added
        • Update due to regulatory directive (committee approval not required in accordance with Reimbursement Policy Program guidelines, Policy #05-017):
          • September 30, 2010, to add New Mexico exemption; removed South Carolina exemption; removed South Carolina -specific policy reference; Background section/policy template updated
        • Update approved November 13, 2009: Tennessee exemption for rules and requirements in separate policy removed— Tennessee rules and requirements in accord with this policy
        • Review approved and effective July 8, 2009: Benefit coverage and authorization information removed; requirement for informational Modifier G7 removed (i.e., does not affect reimbursement); Maryland/New Jersey/Texas Children’s Health Insurance Program/Virginia benefit coverage exemptions removed; New York exemption clarified with reference to free/direct access, authorization, and Modifier G7 removed; South Carolina exemption added; medical criteria references removed; Elective Abortion (Termination of Pregnancy – South Carolina added to Related Policy section
        • Review approved December 14, 2007: NY exemption added
        • Initial committee approved and effective: August 16, 2006
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • American Medical Association
        Definitions:
        • Abortion, Elective/Therapeutic: one resulting from measures taken to intentionally end a pregnancy using medications (medical abortion) or surgery
        • Abortion, Incomplete: part of the product of conception has been retained in the uterus
        • Abortion, Missed: a dead nonviable fetus and other products of conception are retained in the uterus for two or more months
        • Abortion, Septic: there is an infection of the product of conception and the endometrial lining of the uterus usually resulting from attempted interference during early pregnancy
        • Abortion Spontaneous/Miscarriage: occur when a natural cause ends a pregnancy prior to 20 weeks
        • Abortion, Threatened: the appearance of signs and symptoms of possible loss of embryo
        • Stillborn: occur when a natural cause ends a pregnancy after 20 weeks
        • Termination of Pregnancy: synonym for abortion

        Reimbursement Policy Definitions

        Related Policies:
        None
        Related Material:
        None
             expand Assistant at Surgery (Modifiers 80/81/82/AS)
        Effective Date:11/5/2012
        Policy:
        Amerigroup allows reimbursement for procedures eligible for an assistant at surgery when billed with Modifiers 80, 81, 82 or AS, as applicable, unless otherwise noted in Exhibit A or by provider, state, federal or CMS contracts or requirements.  Amerigroup uses code editing software to process claims billed for assistant at surgery. If an applicable modifier is not billed appropriately, the procedure may be denied. 

        When multiple procedures are performed where only some of the procedures are eligible for assistant at surgery reimbursement, only assistant at surgery services for the eligible procedures will be considered for reimbursement. The same multiple-procedure fee reductions and clinical edits apply to both the assistant at surgery and the primary surgeon.

        The assistant at surgery should not report procedure codes different from the procedure codes reported by the primary surgeon, EXCEPT if the primary surgeon bills a global code (e.g., maternity ante-partum, delivery and postpartum), then the assistant at surgery would bill the specific surgery code (e.g., delivery only) with the appropriate modifier.
        Exemptions:
        • Amerigroup Florida, Inc. requires the primary surgeon and assistant surgeon to bill the same procedure code in all cases, in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbook.
        • Amerigroup Texas, Inc. and Amerigroup Insurance Company allow assistant at surgery reimbursement to an enrolled physician assistant when the service is billed with Modifier 80 and U7.
        Policy History:
        • Approved and effective 11/05/12: Washington, Kansas and Louisiana added to Exhibit A
        • Review approved 06/06/11 and effective 12/07/2011: added code editing language; removed modifier percentages; removed SC from Exhibit A; updated Background and Definitions sections and policy template
        • Review approved 06/01/09:  Exhibit added to clarify market-specific reimbursement with OH information clarified and SC, NV, and NM added; TX exemption identifying nurse practitioner fee schedule removed; TX exemption clarifying physician assistant modifier usage added; Background section/policy template updated
        • Review approved 05/30/07:  TX exemption identifying nurse practitioner fee schedule percentage added; denial for inappropriate modifier billing clarified
        • Review approved 05/22/06:  FL exemption added
        • Initial committee approval and effective: 03/03/06
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        •  State Medicaid
        • Amerigroup State Contracts
        • Ingenix Learning: Understanding Modifiers, 2010 edition
        Definitions:
        • Modifier 80: denotes an assistant at surgery providing full assistance to the primary surgeon
        • Modifier 81: denotes an assistant at surgery providing minimal assistance to the primary surgeon
        • Modifier 82: denotes an assistant at surgery when a qualified resident surgeon is not available to assist the primary surgeon
        • Modifier AS: denotes an assistant at surgery who is a non-physician (e.g. physician assistant, nurse practitioner)

        Reimbursement Policy Definitions

        Related Policies:
        • Code and Clinical Editing Guidelines
        • Modifier Usage
        Related Material:
             expand Global Surgical Package for Professional Providers
        Effective Date:7/17/2006
        Policy:

        Amerigroup allows reimbursement for the global surgical package unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

        The global surgery package may be furnished in any setting and reimbursement applies to both major and minor surgical procedures as defined by their postoperative periods of 90, 10 or 0 days.

        Included in the Global Surgical Package

        Reimbursement for the following components is included within the global surgical package:

        • Preoperative services rendered after the decision is made to operate, beginning with the day before major procedures and the day of surgery for minor procedures
        • Intraoperative services that are normally a usual and necessary part of a surgical procedure
        • Treatment for all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room and are not categorized as a Hospital-Acquired Condition (HAC) or Present on Admission (POA)
        • Postsurgical pain management by the surgeon
        • Visits during the postoperative periods that are related to recovery from the surgery
        • Miscellaneous surgical services and supplies used during the surgery

        Unlisted Surgical Procedures Included in Global Package

        Reimbursement for an unlisted surgical procedure is based on the review of the unlisted code on an individual claim basis. Claims submitted with unlisted codes must contain the any of the following information and/or documentation describing the procedure or service performed for consideration during review:

        • Written description
        • Office notes
        • Operative report

        Add-on Surgical Procedures Included in Global Surgical Package

        The global surgical period for an add-on surgical procedure will be based on the primary surgical code.

        Separately Reimbursable from Global Surgical Package

        The following services are not included in the payment amount for the global surgery. The services listed below are separately reimbursable expenses:

        • The initial consultation or evaluation by the surgeon to determine the need for a major surgical procedure
        • Visits during the postoperative period of surgery that are unrelated to the diagnosis of the surgery, unless the visits occur due to complications of the surgery
        • Treatment for an underlying condition or an added course of treatment which is not part of the normal recovery from surgery
        • Diagnostic tests and procedures
        • Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications
        • Treatment for postoperative complications which require a return trip to the operating room
        • If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately
        • Immunosuppressive therapy for an organ transplant
        • Critical care services unrelated to the surgery where a seriously injured or burned member is critically ill and requires constant attendance of the physician

        Providers must use applicable HIPAA-compliant modifiers for any services provided during the post-operative period. These modifiers are appended to the corresponding CPT/HCPCS code in conjunction with an appropriate diagnosis code for reimbursement consideration.

        Exemptions:

        Amerigroup Ohio, Inc. allows facilities to bill certain surgical unlisted codes without documentation of a written description, office notes, or operative report describing the procedure or service performed, and to be reimbursed based on a percentage determined by the state of Ohio or the provider’s contract. Amerigroup reserves the right to request medical records to support the claim. [NOTE: This exemption does not apply if the facility provides a description for the unlisted code and an established code exists to describe the service.]

        Policy History:
        • Review approved 11/21/11 and effective 07/17/06:background section and policy template updated; POA/HAC language added; minor language clarifications
        • Review approved 10/11/10: Unlisted Surgical Procedures and Add-on Surgical Procedures sections added; OH exemption added; Background section/policy template updated.
        • Review approved 09/21/09: Background section/policy template updated.
        • Initial committee approval and effective: 07/17/06
        Reference and Research Material:

        This policy has been developed through consideration of the following:

        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        • McKesson ClaimCheck® Code Edit Guidelines
        Definitions:
        Related Policies:
        • Claims Requiring Additional Documentation
        • Duplicate or Subsequent Services on the Same Date of Service
        • Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during the Postoperative Period
        • Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
        • Modifier 54: Surgical Care Only
        • Modifier 55: Post-operative Management Only
        • Modifier 56: Pre-operative Management Only
        • Modifier 57: Decision for Surgery
        • Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period
        • Modifier Usage
        • Unlisted and Miscellaneous Codes (aka: Dump Codes)
        Related Material:

        None

             expand Hysterectomy
        Effective Date:2/12/2009
        Policy:
        Amerigroup allows reimbursement of nonelective and medically necessary hysterectomy procedures for covered members unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and receipt of a valid consent/acknowledgement of hysterectomy form.
         
        Amerigroup considers reimbursement for a hysterectomy only when the following criteria is met:
        • The hysterectomy is medically necessary to treat an illness or injury
        • The member has given informed consent
        • The member or authorized representative is fully aware that the hysterectomy will render the member permanently incapable of reproducing and has orally and in writing expressed this understanding
        • The member or authorized representative has signed and dated an applicable state-approved Consent/Acknowledgement of Hysterectomy Form. The form is required regardless of the member’s diagnosis or age

        [NOTE: The Consent/Acknowledgement of Hysterectomy Form with the physician’s certification is required if the individual was already sterile before the hysterectomy or if the individual required a hysterectomy because of a life threatening emergency situation in which the physician determined that prior consent/acknowledgement was not possible. The member’s informed consent/acknowledgement of hysterectomy is not required.]

        Claims for both professional and facility services for a hysterectomy procedure submitted without the valid informed consent/acknowledgement of hysterectomy form will be denied. A valid Consent/Acknowledgement of Hysterectomy Form includes all required signatures:

        • Member, except as noted
        • Person obtaining the member’s consent
        • The physician performing the hysterectomy procedure

        If a hysterectomy procedure is performed in conjunction with a delivery, then multiple surgery guidelines apply (refer to Amerigroup Multiple and Bilateral Surgery Policy).

        Nonreimbursable

        Amerigroup does not allow reimbursement of a hysterectomy procedure in the following circumstances:

        • If the hysterectomy is performed for the sole purpose of rendering the member permanently incapable of reproducing
        • When there is more than one reason for the hysterectomy, but the primary reason is to render the member permanently incapable of reproducing a child
        • The hysterectomy is performed for the purpose of cancer prophylaxis
        Exemptions:
        Amerigroup does not require informed Consent/Acknowledgement of Hysterectomy Forms submitted with claims under the Amerivantage product; however, the form will be required for coordination of benefits if a claim for the same member is also submitted under an Amerigroup Medicaid product.
        Policy History:
        • Review approved September 30, 2011, and effective February 12, 2009: accountability language updated; background references updated; South Carolina exemption removed; acknowledgement of hysterectomy form language added
        • Update approved November 13, 2009: Tennessee exemption for rules and requirements in separate policy removed— Tennessee rules and requirements in accord with this policy
        • Review approved December 29, 2008, and effective December 12, 2009: Consent form criteria clarified; medical criteria removed; South Carolina and Amerivantage exemptions added
        • Initial committee approval and effective date: December 12, 2006
        Reference and Research Material:
        This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice and review of medical literature and government approval status, in addition to the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • Aetna clinical policy bulletins
        • American College of Obstetricians and Gynecologists (ACOG)
        Definitions:
        Related Policies:
        • Multiple and Bilateral Surgery Reimbursement
        Related Material:
        • Hysterectomy Acknowledgment Form/Acknowledgment of Receipt of Hysterectomy Information
        • Instructions for Completing the Hysterectomy Acknowledgment Form
             expand Multiple and Bilateral Surgery: Professional and Facility Reimbursement
        Effective Date:7/16/2012
        Policy:
        Amerigroup allows reimbursement to professional providers and facilities for multiple and bilateral surgery, unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements. Reimbursement is based on Medicaid-based or Medicare-based multiple fee reductions in accordance with applicable contracts or state guidelines for applicable surgical procedures performed at the same session by the same provider.
         
        Multiple Surgery
        Professional provider claims for applicable surgical procedures must be billed with Modifier 51 to denote a multiple surgery. Facility claims should not be billed with Modifier 51. However, the following fee reductions apply to both physician and facility claims. Medicaid-based reimbursement is the total of:
        • 100 percent of the fee schedule or contracted/negotiated rate for the primary (i.e., highest valued) procedure
        • 50 percent for the secondary procedure
        • 25 percent for third through fifth procedures with the sixth and additional procedures only if determined to be medically necessary through clinical review

        Medicare-based reimbursement is the total of:

        • 100 percent of the fee schedule or contracted/negotiated rate for the primary (i.e., highest valued) procedure
        • 50 percent for the second through fifth procedures
        • 50 percent for the sixth and additional procedures only if determined to be medically necessary through clinical review

        Bilateral Surgery
        Professional provider and facility claims with applicable surgical procedures must be billed with Modifier 50 to denote a bilateral surgery. It is inappropriate to use Modifier LT or RT to identify bilateral procedures. Medicare-based and Medicaid-based reimbursement is 150 percent of the fee schedule or contracted/negotiated rate of the procedure.

        For procedure codes containing bilateral or unilateral in their description, no modifier is used, and reimbursement is based on 100 percent of the fee schedule or contracted/negotiated rate for the procedure.

        In the instance when more than one bilateral procedure or multiple and bilateral procedures are performed during the same operative session, the multiple fee reductions apply.

        Claims with applicable surgical procedures billed without the correct modifier to denote either multiple or bilateral surgery may be denied.

        Exemptions:
        • Amerigroup Nevada, Inc. reimburses 100/50/25/10/5 in accordance with Nevada Department of Health and Human Services.
        • Amerigroup Texas, Inc. allows facility reimbursement for only the procedure with the highest surgical code grouping when multiple surgical procedures are performed on the same day
        • Amerigroup does not apply multiple fee reduction reimbursement to modifier-51 exempt (also known as MS-exempt) or add-on procedure codes since the fee allowance and/or relative value is already reduced for the procedure itself
        Policy History:
        • Review approved and effective 07/16/12: Policy template updated, Nevada exemption added.
        • Review approved and effective August 16, 2010: Policy adapted from Multiple and Bilateral Surgery Reimbursement – Facility, #07-035, approved September 10, 2007 and Multiple and Bilateral Surgery Reimbursement – Professional Providers, #06-010, approved April 19, 2006. Modifier use and fee reductions for facility claims clarified; reference material updated to indicate 2010 edition.
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        • National Uniform Billing Committee Guidelines
        • Ingenix Learning: Understanding Modifiers, 2010 edition
        • McKesson ClaimCheck® Code Edit Guidelines
        Definitions:
        Related Policies:
        • Assistant at Surgery (Modifiers 80/81/82/AS)
        • Modifier Usage
        Related Material:
        None
             expand Robotic Assisted Surgery
        Effective Date:9/11/2011
        Policy:

        Amerigroup does not allow separate or additional reimbursement for the use of robotic surgical systems unless provider, state, federal, or CMS contracts or requirements indicate otherwise. Codes indicating robotic surgical systems will be denied or subject to recoupment.

        Providers should not append surgery codes with Modifier 22 (Increased Procedural Service) to indicate robotic-assisted surgery in order to receive separate or additional reimbursement for use of robotic surgical systems. Claims billed with Modifier 22 to indicate robotic-assisted surgery will be denied or subject to recovery or recoupment of payment.

         

        Exemptions:
        There are no exemptions to this policy.
         
        Policy History:

        Committee approval February 28, 2011: policy adapted from prior policy, robotic-assisted surgeries (#06-113), effective October 17, 2006, and retired October 20, 2008.

         

        Reference and Research Material:

        This policy has been developed through consideration of the following:

        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • U.S. Food and Drug Administration (FDA)
        Definitions:
        Related Policies:

        Modifier 22: Increased Procedural Service

         

        Related Material:
        None
         
             expand Split-Care Surgical Modifiers
        Effective Date:3/16/2012
        Policy:
        Amerigroup allows reimbursement of surgical codes appended with split-care modifiers, unless provider, state, federal or CMS contracts or requirements indicate otherwise.

        Reimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. The percentage is determined by which modifier is appended to the procedure code:
        • Modifier 54 (surgical care only — 70 percent
        • Modifier 55 (postoperative management only) — 20 percent
        • Modifier 56 (preoperative management only) — 10 percent

        The global surgical package consists of preoperative services, surgical procedures and postoperative services. Total reimbursement for a global surgical package is the same regardless of how the billing is split between the different physicians involved in the member’s care. When more than one physician performs services that are included in the global surgical package, the total amount reimbursed for all physicians may not be higher than what would have been paid if a single physician provided all services.

        Correct coding guidelines require the same surgical procedure code (with the appropriate modifier) be used by each physician to identify the services provided when the components of a global surgical package are performed by different physicians.

        When an assistant surgeon is used and/or multiple procedures are performed, assistant surgeon and/or multiple procedure rules and fee reductions apply.

        Exemptions:
        • Amerigroup Florida Inc. reimburses surgical procedure codes appended with the appropriate split-care modifier at the percentage indicated below, in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbooks:
          • Modifier 54: 50 percent
          • Modifier 55: 30 percent
          • Modifier 56: 20 percent
        • Amerigroup Maryland Inc. does not recognize Modifier 56, and reimburses surgical procedure codes appended with the appropriate split-care modifier at the percentage indicated below, in compliance with the Maryland Department of Health and Mental Hygiene regulations:
          • Modifier 54: 80 percent
          • Modifier 55: 20 percent
        Policy History:
        • Review approved 11/07/11 and effective 3/16/12: Policy adapted from Modifier 54: Surgical Care Only (#06-012), Modifier 55: Postoperative Management Only (#06-013), and Modifier 56: Preoperative Management Only (#06-014) policies; MD exemption added; definitions section updated; reference materials updated to indicate 2010 editions; policy template updated
        • Initial committee approval 05/04/06
          • Modifier 54: Surgical Care Only effective: 10/01/06
          • Modifier 55: Postoperative Management Only effective: 05/04/06
        • Modifier 56: Preoperative Management Only effective: 05/04/06
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup State Contracts
        • Ingenix Learning: Understanding Modifiers, 2010 edition
        Definitions:
        Modifier 54: Used to indicate that a surgeon performed only the surgical component of a global surgical package (e.g., another physician provides postoperative care).

        Modifier 55: Used to indicate that a physician other than the surgeon performed only the postoperative management component of a global surgical package.

        Modifier 56: Used to indicate that a physician other than the surgeon performed only the preoperative evaluation component of a global surgical package.
         
        Related Policies:
        • Assistant at Surgery (Modifiers 80/81/82/AS)
        • Clinical Code Editing Guidelines
        • Modifier Usage
        • Multiple and Bilateral Surgery Reimbursement
        Related Material:
        None
             expand Sterilization
        Effective Date:4/15/2013
        Policy:
        Unless otherwise noted by provider, state, federal, or CMS contracts and/or requirements, Amerigroup allows reimbursement of sterilization procedures for covered members. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and receipt of a
        valid consent form.

        Amerigroup considers reimbursement of sterilization procedures based on the following guidelines:  
        • The member has given informed consent by voluntarily signing the applicable consent form:
          • At least 30 days but not more than 180 days (excluding the consent and surgery dates) must have passed between the date of written informed consent and the date of sterilization, except in cases of a premature delivery or emergency surgery.
          • An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours has passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must been given at least 30 days before the expected date of delivery.

        At the time of informed consent, the member must meet all of the following criteria:

        • Be at least 21 years of age
        • Be mentally competent 
        • Not be institutionalized (e.g., mental hospital or correctional facility)

        The applicable state sterilization consent form must be submitted to Amerigroup. Claims for professional and facility services for a sterilization procedure will be denied if Amerigroup has not received a valid consent form. A valid consent form includes all required signatures:

        • Member or member’s authorized representative
        • Interpreter, if applicable
        • Person obtaining the member’s consent
        • Physician performing the sterilization procedure

        If a sterilization procedure is performed in conjunction with a delivery, then multiple surgery guidelines apply.

        Exemptions:
        • Amerigroup Louisiana, Inc. does not allow reimbursement of sterilization procedures when:
          • Member is under the influence of alcohol at the time consent is obtained
          • Member is in the hospital for labor/childbirth/abortion at the time consent is obtained
        • Amerigroup Tennessee, Inc. does not allow reimbursement of Sterilization procedures when performed in conjunction with a vaginal or caesarean delivery with sterilization when reimbursed using DRG methodology.
        • Amerigroup New Jersey, Inc. requires providers to submit the informed consent form for all sterilizations including those due to premature delivery or emergency abdominal surgery.
        • Amerigroup does not require informed consent forms submitted with claims under the Amerivantage product; however, the form will be required for coordination of benefits if a claim for the same member is also submitted under an Amerigroup Medicaid product.
        Policy History:
        • Review approved 07/30/12 and effective 04/15/13: TN and LA exemptions added; NJ exemption updated; policy template and background updated
        • Review approved 05/03/10 and effective 09/07/10: Updated consent form receipt requirements; added required signatures to include member’s authorized representative and interpreter; added Amerivantage
          exemption; deleted benefit coverage information; removed TN and SC exemptions; updated template format.
        • Review approved and effective 07/14/08: NJ exemption added.
        • Initial committee approval and effective 12/12/06.
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • American College of Obstetricians and Gynecologists
        Definitions:
        Related Policies:
        • Multiple and Bilateral Surgery
        Related Material:
        None
        collapse Transportation
             expand Transportation Services: Ambulance and Non-Emergent Transport
        Effective Date:2/26/2008
        Policy:

        Amerigroup allows reimbursement for transport to and from covered services or other services mandated by contract, unless otherwise noted by provider, state, federal, or CMS contracts or requirements. Reimbursement is based on the following guidelines.

        Due to the complex nature of transportation services, Amerigroup recommends that providers also review individual state guidelines for coverage requirements.

        Non-Emergent Transport Services

        Non-Emergency Medical Transport (NEMT) entails the transport of a member by nonmedically skilled personnel (laypersons) to receive covered services. There are several types of medical transports: ambulette/medi-van, wheelchair van, invalid coach, taxicab, mini-bus and public transportation (e.g., bus and/or subway).

        In some instances, NEMT services are provided through a state vendor, not Amerigroup, in the states indicated in the exemptions section of this policy.

        Reimbursement for medical transport services is based on receipt of a claim or an invoice from contracted transportation vendors or other suppliers detailing:

        • The nonemergency medical transport base rate per trip, where a trip is defined by the origin and destination modifiers
        • Mileage
        • Parking and/or toll fees

        AMBULANCE SERVICES

        Reimbursement for ambulance services is based on:

        • The ambulance base rate per trip in accordance with the medically necessary level of care provided to the member, where a trip is defined by the origin and destination modifiers
        • The fee schedule or contracted/negotiated rate for services and items separately reimbursable from the ambulance base rate
        • If ambulance transport is medically necessary for inpatient-to-inpatient transfer between hospital-based facilities, reimbursement is included in the inpatient stay

        Included in the Ambulance Base Rate

        Services reimbursed as part of the ambulance base rate:

        • Ambulance equipment and supplies:
          • Disposable/first aid supplies
          • Reusable devices/equipment
          • Oxygen
          • Intravenous (IV) drugs
        • Ambulance personnel services

        Separately Reimbursable from the Ambulance Base Rate

        Services that are not part of the ambulance base rate are separately reimbursable expenses:

        • Mileage
        • Additional appropriately licensed medical personnel as medically necessary for member’s health status
        • Unusual waiting time (i.e., in excess of 30 minutes)
        • Disposable/first aid supplies in greater than normal use

        Transportation Modifiers

        Claims for transportation services must be billed with the following origin and destination modifiers. Claims for transportation services submitted without origin and destination modifiers will be denied.

        • Modifier D: diagnostic or therapeutic site/free standing facility other than P or H
        • Modifier E: residential, domiciliary, custodial facility (e.g., nursing home, not a skilled nursing facility)
        • Modifier G: hospital-based dialysis facility (hospital or hospital-associated)
        • Modifier H: hospital (inpatient or outpatient)
        • Modifier I: site of transfer (e.g., airport or helicopter pad) between types of ambulance
        • Modifier J: nonhospital-based dialysis
        • Modifier N: Skilled Nursing Facility (SNF), including swing bed
        • Modifier P: physician’s office, including HMO nonhospital facility, clinic, etc.
        • Modifier R: private residence
        • Modifier S: scene of accident or acute event
        • Modifier X: intermediate stop at the physician’s office en route to hospital (includes HMO nonhospital facility, clinic, etc.)
          • Modifier X can only be used as a destination code in the second position of a modifier

        In addition to the origin and destination modifiers, the following modifiers are to be used when appropriate:

        • Modifier GM: indicates multiple members on one trip
        • Modifier QL: indicates the member died after the ambulance was called
        • Modifier QM: indicates the provider arranged for the transportation services
        • Modifier QN: indicates the provider furnished the transportation services
        • Modifier TK: indicates multiple carry trips
        • Modifier TQ: indicates life support transport by a volunteer ambulance provider
        • modifiers for transportation of portable/mobile radiology equipment

        Nonreimbursable

        Amerigroup does not allow reimbursement of the following for any ambulance or medical transport service provided:

        • A member who is not available (i.e., no-show)
        • Additional rates for night, weekend, and/or holiday calls
        • Mileage in transit to pick up or drop off the member (e.g., unloaded mileage)
        • Mileage for additional passengers
        • Mileage for extra attendant for additional passengers
        • Transport for a member’s or caregiver’s convenience
        • Transport available free of charge
        • For ambulance services only:
          • For reasons other than medical care
          • Where another means of transportation (e.g., medi-van, public transportation) could be used without endangering the member’s health
          • For separate reimbursement for services/items included in the base ambulance rate
          • For a higher level of care when a lower level is more appropriate (e.g., Advanced Life Support (ALS) service when Basic Life Support (BLS) is appropriate)
          • For both basic and advanced life support when ALS services are provided
          • For services provided by the Emergency Medical Technician (EMT) in addition to ALS or BLS base rates
          • For services provided on the ambulance by hospital staff
          • Additional ground and/or air ambulance providers that respond but do not transport the member
          • Transport from the member’s home to a facility other than a hospital, skilled nursing facility, dialysis facility or nursing home
          • Transport from a facility other than a hospital, skilled nursing facility, dialysis facility or nursing home to the member’s home
          • Transport of persons other than the member and a medically required attendant who do not require medical attention
          • Transport for a member pronounced dead prior to the ground and/or air ambulance being contacted
          • Mileage beyond the nearest appropriate facility (i.e., excessive mileage)
        • For medical transport services only:
          • Transportation vendor/supplier lodging or meals vehicle maintenance or gas
        Exemptions:
        • Amerigroup New York LLC allows reimbursement of ambulance transport separate from the inpatient stay when a newborn infant is transported from the birth hospital to a Regional Perinatal Care Center, in compliance with state guidance.
        • Amerigroup Texas Inc. and Amerigroup Insurance Company, in compliance with the Texas Medicaid Provider Procedures Manual allows:
          • Reimbursement of the following separate from the ambulance base rate:
            • Basic Life Support (BLS) and Advanced Life Support (ALS) routine disposable supplies; and
            • Ambulance oxygen and oxygen supplies
          • Reimbursement of mileage separate from the base rate for medical transport
        • Amerigroup Virginia Inc., in compliance with Virginia Department of Medical Assistance Services provider manuals:
          • Only allows reimbursement for the mode of transport, mileage, and wait times in excess of 30 minutes
          • Does not require providers to bill modifiers on transportation claims
        • Transportation services are provided through a state vendor, not Amerigroup, for certain situations in the markets listed below. Providers are advised to review their individual state guidelines for coverage and other requirements.
        Policy History:
        • Update due to regulatory directive 10/24/11 (Committee Approval not required in accordance with Reimbursement Policy Program Guidelines; updated Transportation exemptions to include NY and NJ when referring to state guidelines for coverage and other requirements; hyperlinks added to states in exemption
        • Review approved 12/06/10: policy adapted from the following policies: Transportation Services–Ambulance (#07-036); Transportation Services–Medical Transport (#07-037); and Transportation Modifiers (#07-038); NY/TX/VA exemptions added; vendor exemption added; benefit-specific exemptions removed. (FL/GA/MD/NJ/NY/TX/VA); modifiers updated; Background and Definitions sections updated; policy template updated
        • Initial committee approval and effective:
          • Transportation Services—Ambulance: approved 10/05/07; effective 02/26/08
          • Transportation Services—Medical Transport: approved 10/05/07; effective 02/26/08
        • Transportation Modifiers—approved 10/17/07; effective 02/26/08
        Reference and Research Material:
        This policy has been developed through consideration of the following:
        • CMS
        • State Medicaid
        • Amerigroup state contracts
        • Ingenix Learning: Understanding Modifiers, 2010 edition
        Definitions:

        Ambulance Services: Ambulance services entail the medically necessary transport of a member by medically skilled personnel to the nearest appropriate facility equipped to provide care for the member’s injury and/or illness. Services are initially delineated as Basic Life Support (BLS) or Advanced Life Support (ALS) levels of care, and then further delineated as emergency or non-emergency:

        • BLS consists of noninvasive services provided by personnel trained as Emergency Medical Technicians (EMTs) (basic) in conjunction with applicable state laws
        • ALS consists of invasive services provided by personnel trained as EMTs (intermediate or paramedic) in conjunction with applicable state laws
        • Emergency ambulance transportation is an urgent service in which the member experiences a sudden, unexpected onset of acute illness or accidental injury requiring immediate medical or surgical care which the member secures immediately after the onset, (or as soon thereafter as practical) and if not immediately treated, could result in death or permanent impairment to the member’s health
        • Nonemergency ambulance transportation is a scheduled or unscheduled service in which the member requires attention by EMT-trained personnel while in transit

        Ambulance Types: There are two types of ambulance transports:

        • Ground ambulance—an equipped and staffed land or water vehicle designed to transport a member in the supine position
        • Air ambulance—an equipped and staffed aircraft necessary to rapidly transport a member to the nearest appropriate facility that could not otherwise be accomplished or be accessed by a ground ambulance without endangering the member’s health. Air ambulances are either rotary-wing (helicopter) or fixed-wing (commercial or private aircraft)

        Medical Transport Services: Medical Transport Services, also referred to as NEMT, entails the transport of a member by nonmedically skilled personnel (laypersons) to receive covered services. There are several types of medical transports: ambulette/medi-van, wheelchair van, invalid coach, taxicab, mini-bus and public transportation (i.e. bus and/or subway).

        Transportation Modifiers: single alpha characters with distinct definitions that are paired together to form a two-character modifier; the first character indicates the origination of the member, and the second character indicates the destination of the member

        Reimbursement Policy Definitions

        Related Policies:
        Portable/Mobile Radiology Services
        Related Material:
        None