Clinical and Payment Policies Notice

Date: 11/01/18

Dear Provider,

Ambetter from Peach State Health Plan is publishing its Payment and Clinical Policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. We will apply these policies as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that Ambetter from Peach State Health Plan currently employs.

Ambetter from Peach State Health Plan believes that publishing this information will help providers to bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments. However, once these policies have been published, some providers will observe claims processing edits that assure only accurately and appropriately coded and billed services are reimbursed.

The nature of these policies addresses coding inaccuracies including diagnosis to procedure code mismatch, inappropriately modified procedures, unbundling, incidental procedures, duplication of services, non-covered services and health plan specific payment rules for procedures and services. These policies are developed based on medical literature and research, industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state of Georgia or regulations.

Determinations for non-payment or reduced payments are based upon the resources listed previously for which the provider is liable, and do not represent opportunities for providers to balance bill patients. The American Medical Association (AMA) in conjunction with multiple specialty societies, CMS and representatives from multiple health care insurers maintain and update the CPT® codes, and establish the rules for the proper use of the CPT and other procedure codes. Guidelines governing the use of the codes and modifiers are clearly delineated in the CPT annual publications as well as other supporting documents published by the AMA. CMS further clarifies and defines the proper use of codes, combinations of codes as well as the combinations of codes and modifiers in multiple publications and databases. Coverage provisions are adopted from specialty society guidelines, the published peer reviewed medical literature, Medicare policy, and local standards of medical care.

Ambetter from Peach State Health Plan takes the responsibility of detecting fraudulent, wasteful and inaccurately or inappropriately billed claims very seriously. These improvements to our detection activities will enable us to more effectively prevent incorrect payment of claims and provide equitable reimbursement to all providers.

We are aware that these improved procedures will impact some claims payments for providers, and there will be a period of adjusting to the implementation of these policies. We are committed to being fair and consistent to providers, patients, and our clients as we pursue our goal of ensuring correct payment of healthcare claims.

The effective date for the below policies is November 1st, 2018.