This FAQ was revised on September 3, 2019.
These frequently asked questions (FAQs) were developed to answer questions about the AmeriHealth new claim payment policy that changes reimbursement for multiple therapies for outpatient facility providers, specifically to include physical, occupational, and speech therapy services.
This document will be updated as additional information becomes available.
1. What changes is AmeriHealth making to its claim payment policy for multiple therapies?
AmeriHealth will implement a new claim payment policy for multiple therapies for outpatient facility providers, specifically to include physical, occupational, and speech therapy services. This claim payment policy will apply to specific CPT® and HCPCS codes designated by the Centers for Medicare & Medicaid Services (CMS) as “Always Therapy” for these services. AmeriHealth will include full payment for the procedure with the highest total allowance and reduced payment for each subsequent procedure provided by the same provider, for the same member, on the same date of service.
2. What is the effective date of the changes to the new claim payment policy for multiple therapies? (Revised 9/3/2018)
Claim Payment Policy #00.01.68: Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services was posted to our Medical Policy Portal as a Notification on August 1, 2019, and went into effect September 1, 2019.
3. What CPT and HCPCS codes are included in this policy?
The CPT and HCPCS codes that are included in this policy are listed in Attachment A of the policy.
4. Are any services exempt from the changes to the claim payment policy for multiple therapies?
Yes. Services conducted in an inpatient facility are not included in this claim payment policy.
5. How will claims with multiple procedures be processed?
Facility outpatient therapy claims, when multiple physical, occupational, and speech therapy services designated as “Always Therapy” are reported by the same provider, for the same member, on the same date of service will be processed as follows:
- The procedure code with the highest total allowance is eligible for reimbursement at
100 percent of the provider's applicable contracted rate. - Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.
In addition, multiple procedures may be submitted on one claim or on multiple claims. This claim payment policy for services designated as “Always Therapy” are based on the date of service regardless of the date the claim was submitted or received.
6. Who will be affected by the claim payment policy for multiple therapies?
The changes affect AmeriHealth-participating outpatient facility providers performing multiple therapies. The changes to this policy affect HMO, POS, EPO, and PPO products.
7. Can I dispute the reimbursement rate I received based on the claim payment policy for multiple therapies?
This is a claim payment policy and assumes services have been documented and billed in a manner that is consistent with applicable coding guidelines. Notice of this claim payment policy was provided in accordance with the terms of our provider contracts. As a participating provider, you agree to comply with changes that may be made by AmeriHealth to claim payment and other policies from time to time. Therefore, changes to this claim payment policy are not eligible for dispute, review, or appeal. However, if you think that the reimbursement reduction applied under this policy is not in accordance with your applicable contracted rate, you may follow the dispute resolution process in your provider agreement.
8. How will I know if I have a claim that is affected by the claim payment policy changes?
Claims affected by this claim payment policy for multiple therapies will appear on your electronic remittance report (835) and/or paper Provider Remittance with a CO59 code.
9. How have providers been notified of the changes to the claim payment policy for multiple therapies? (Revised 9/3/2018)
- On August 1, 2019, policy changes were announced to providers via:
- Medical Policy Portal;
- Partners in Health UpdateSM, our online provider newsletter;
- AmeriHealth NaviNet® web portal (NaviNet Open) Plan Central in a message containing a summary of the changes to the policy and a link to the Medical Policy Portal.
- On August 6, 2019, a Provider Bulletin was also sent to facilities as a notification of the new policy.
- On September 3, 2019, providers were reminded of the new policy via:
- Partners in Health Update
- AmeriHealth NaviNet Open Plan Central
For more information
Please refer to the Medical Policy Portal to view the most recent version of the policy, as it will supersede the information in this FAQ.
If you cannot find the information you are looking for here and have further questions, please call 1-888-YOUR-AH1 for AmeriHealth New Jersey and 1-800-275-2583 for AmeriHealth Pennsylvania.
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