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  These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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

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expand Anesthesia
expand Coding
Assistant at Surgery (Modifiers 80/81/82/AS)
Modifier 22: Increased Procedural Service
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Modifier 59: Distinct Procedural Service
Modifier 63: Procedure Performed on Infants less than 4 kg
Modifier 76: Repeat Procedure by the Same Physician
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
Multiple and Bilateral Surgery: Professional and Facility Reimbursement
Reimbursement of Services with Obsolete Codes
Split-Care Surgical Modifiers
expand Drugs
Drugs and Injectable Limits
expand Evaluation and Management
Consultations
Preventive Medicine and Sick Visits on the Same Day
expand Facilities
expand Medicine
Allergy Treatment: Immunotherapy
expand Prevention
Vaccines for Children (VFC) Program
expand Prosthetics and Orthotics
expand Radiology
Multiple Radiology Payment Reduction
expand Reimbursement Administration - General
Claims Requiring Additional Documentation
Claims Submission – Required Information for Professional Providers
Code and Clinical Editing Guidelines
Duplicate or Subsequent Services on the Same Date of Service
Emergency Services: Non-Participating Providers and Facilities
Inpatient Readmissions
Medical Recalls
Present on Admission Indicator for Health Care-Acquired Conditions
Reimbursement of Claims with Charge Discrepancies
Requirements for Documentation of Proof of Timely Filing
expand Surgery
Abortion (Termination of Pregnancy)
Hysterectomy
Robotic Assisted Surgery