Please note the following billing reminders for hospitals.

Quarterly fee schedule updates for all hospitals

As outlined in your Hospital Agreement (Agreement), due to changes in clinical practice and/or modifications to standard coding systems, we may add, delete, and/or re-categorize the fee schedule for outpatient procedures. AmeriHealth provides a 30-day written advance notice to facilities of such changes. It is imperative that these changes are reviewed to ensure accurate billing and claims reimbursement.

If a particular outpatient procedure is not listed on the applicable fee schedule, but we agree that it is a covered service, the following pricing rules will apply:

• Surgical services: AmeriHealth will establish a fee for the procedure in question, based on the current fees for similar services.
• Non-surgical services: Payment will be made based on the applicable ?Percentage of Charges? until a fee is established.

AmeriHealth or its authorized representative has the right to review, within reason and with timely notice to the hospital, medical records pertaining to an outpatient service provided to members subject to the terms and conditions within your Agreement. In some instances, this may be necessary in establishing a fee for services rendered.

For hospitals contracted under APC: Proper billing practices

On January 1, 2012, Ambulatory Payment Classifications (APC) reimbursement was added to your Agreement for certain AmeriHealth products. According to that Agreement, the APC Grouper/Pricer and Fee Schedules published and distributed by the Centers for Medicare & Medicaid Services (CMS) are used to determine reimbursement. The reimbursement amount is the product of the CMS APC Pricer amount (or fee schedule amount) and the CMS Pricer Adjustment Factor.

As of January 2016, CMS implemented updates to the Hospital Outpatient Prospective Payment System, OPPS (APC Pricer). It is important that you have the most current version of the pricing application to ensure compliant billing practices. Use of the inappropriate version may result in inaccurate reimbursement.

For services applicable to APC reimbursement, when a provider has more than one National Provider Identifier (NPI) based on the specialty of service(s) they provide, he or she must use the NPI and coordinating taxonomy code that is specific to acute-care services. This enables the accurate application of the provider?s contractual business arrangements with AmeriHealth. Failure to submit claims with the applicable NPI and correct correlating taxonomy code may result in incorrect claim processing and/or payment delays.

Please review the following examples and share this information with your billing staff/vendor.

For hospitals not contracted under APC: Modifier pricing

If you are a facility that is contracted according to the outpatient fee schedule, meaning non-APC reimbursement, AmeriHealth does not acknowledge modifiers. The application of modifier pricing is administered on APC-based outpatient contracts only.

If you have any questions about these important billing reminders, please contact your Provider Partnership Associate or Network Coordinator.