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 These policies may be superseded by State, Federal or Centers for Medicare and Medicaid Services (CMS) requirements.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