​​New Implant Reimbursement Request Form for AmeriHealth New Jersey

January 10, 2022

​AmeriHealth New Jersey has developed an implant reimbursement form.* Providers can email or fax the completed form to Provider Relations via:

The following information is required on a completed form:

  • Provider name
  • ​Provider number
  • Member name
  • Member ID number
  • Patient account number
  • Claim number
  • Dates of service (Admit and Discharge)
  • Implant type or CPT® code/Revenue Code
  • Reimbursement amount

Note: The manufacturer invoice, implant record, UB-04 form, and operative report must be attached to the completed form. If not, reimbursement requests will be denied.

Learn more

If you have questions about the implant reimbursement form, please contact your Provider Partnership Associate.

*Implants are paid according to the terms of your Provider Agreement.

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