TX MMP Reimbursement Policies

We want to assist physicians, facilities and other providers in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member’s Amerigroup STAR+PLUS MMP benefits. Keep in mind that determination of coverage under a member’s benefit plan does not necessarily ensure reimbursement. These policies may be superseded by state, federal or CMS requirements. Providers and facilities are required to use industry standard codes for claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The billed code(s) should be fully supported in the medical record and/or office notes. Industry practices are constantly changing and Amerigroup STAR+PLUS MMP reserves the right to review and revise its policies periodically.

Policy Disclaimer >>

Policy Definitions >>

Anesthesia Professional Anesthesia Services  Coding Assistant at Surgery (Modifier 80/81/82/AS) Diagnoses Used in Diagnosis-Related Groups Computation Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) Durable Medical Equipment (DME) Modifiers for New, Rented and Used Equipment Modifier 22: Increased Procedural 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 26 and TC: Professional and Technical Component Modifier 57: Decision for Surgery Modifier 62: Co-Surgeons Modifier 63: Procedure Performed on Infants less than 4 kg Modifier 66: Surgical Teams Modifier 76: Repeat Procedure by the Same Physician Modifier 77: Repeat Procedure by Another 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 91: Repeat Clinical Diagnostic Laboratory Test Modifier Usage Modifiers LT and RT: Left Side/Right Side Procedures Multiple and Bilateral Surgery: Professional and Facility Reimbursement Reimbursement for Reduced and Discontinued Services Reimbursement of Services with Obsolete Codes Split-Care Surgical Modifiers Unlisted, Unspecified or Miscellaneous Codes  DME and Supplies Durable Medical Equipment (Rent to Purchase) Facility Take-Home Durable Medical Equipment and Medical Supplies  Drugs Drugs and Injectable Limits  Evaluation and Management Consultations Preventive Medicine and Sick Visits on the Same Day  Facilities DRG Inpatient Facility Transfers Inpatient Readmissions Preadmission Services for Inpatient Stays  Laboratory Drug Screen Testing  Prosthetics and Orthotics Prosthetic and Orthotic Devices  Radiology Multiple Radiology Payment Reduction Portable/Mobile/Handheld Radiology Services  Reimbursement Administration - General Claims Requiring Additional Documentation Claims Submission - Required Information for Facilities Claims Submissions - Required Information for Professional Providers Claims Timely Filing Code and Clinical Editing Guidelines Corrected Claims Documentation Standards for Episodes of Care Duplicate or Subsequent Services on the Same Date of Service Eligible Billed Charges Emergency Services: Nonparticipating Providers and Facilities Locum Tenens Physicians/Fee-for-Time Compensation Medical Recalls Nurse Practitioner and Physician Assistant Services Preventable Adverse Events Reimbursement for Items Under Warranty Reimbursement for Maximum Units Per Day Reimbursement of Claims with Charge Discrepancies Reimbursement of Sanctioned and Opt-Out Providers Requirements for Documentation of Proof of Timely Filing Scope of Practice Site of Service Payment Differential - Professional  Surgery Abortion (Termination of Pregnancy) Global Surgical Package for Professional Providers Hysterectomy Maternity Services Multiple Delivery Services Robotic Assisted Surgery Sterilization  Transportation Transportation Services: Ambulance and Nonemergent Transport