Providers should continue to bill in accordance with industry standards and correct coding guidelines and follow the medical and claim payment policies as outlined in the Medical and Claim Payment Policy Portal.
AmeriHealth HMO, Inc., AmeriHealth Insurance Company of New Jersey, and AmeriHealth Administrators will continue to apply claim editing to ensure compliance with billing reporting requirements and guidelines endorsed by national and regional industry sources, including but not limited to:
- Centers for Medicare & Medicaid Services (CMS) standards such as:
- Medicare Claims Processing Manual, including but not limited to the National Correct Coding Initiative (NCCI)
- CMS HCPCS LEVEL II Manual coding guidelines
- Durable Medical Equipment Regional Carries (DMERC) Manual
- National Coverage Determinations (NCDs)
- Local Coverage Determinations (LCDs)
- American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
- ICD-10-CM Official Guidelines for Coding and Reporting
- U.S. Food and Drug Administration (FDA)
- Nationally recognized specialty societies such as:
- National Comprehensive Cancer Network (NCCN)
- American College of Obstetricians and Gynecologists (ACOG)
- American Society of Anesthesiologists (ASA)
- American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM)
- U.S. Preventive Services Task Force (USPSTF)
Upcoming changes during our transition
As we begin to prepare for our transition to a new operating platform in January, please be advised that response codes and language for your claim submissions may have a different look and feel depending on which platform the claim was processed. We will share more information on the changes you may experience as we approach January 1, 2024.
In the meantime, you may review the Enhanced Claims Editor Program FAQ for a refresher of the claim editing process that is currently in effect.
We encourage you to frequently visit our dedicated Platform Transition page to stay abreast of the upcoming changes.