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On January 1, 2012, Ambulatory Payment Classifications (APC) reimbursement
was added to the Hospital Agreement (Agreement) for certain AmeriHealth
products in New Jersey and Pennsylvania. According to those Agreements, 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.
In the event CMS makes updates to APC Grouper/Pricer and/or Fee Schedules,
AmeriHealth will update the APC Grouper/Pricer within 60 days* of CMS
publishing such updates. The parties agree, however, that retrospective changes
made by CMS shall not apply.
If you have a concern regarding the way your claims are reimbursed, please
use your applicable version of the CMS Outpatient Prospective Payment System
(APC Pricer) to verify proper compensation.
If discrepancies remain, or if you have any questions, please contact your
Provider Partnership Associate or Network Coordinator.
* The time frame may vary. Please refer to your specific
Agreement with AmeriHealth.
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