AMH Health, LLC (Anthem | MaineHealth) reimbursement policies
Effective January 1, 2020, reimbursement policies will become effective and located on the provider website. AMH Health reimbursement policies apply to providers who serve Medicare Advantage members enrolled in AMH Health. AMH Health reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, AMH Health strives to minimize these variations. To view the updated reimbursement policies, visit the provider self‑service website.
What does this mean to providers?
Please refer to the reimbursement policy website, your provider manual and/or your provider contract as a guide for reimbursement criteria. Reimbursement policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement if the service is covered by a member’s benefit plan. The determination that a service, procedure, item, etc. is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member’s state of residence. Proper billing and submission guidelines are required along with the use of industry-standard, compliant codes on all claim submissions.
We reserve the right to review and revise our policies when necessary. Reimbursement policies go through a review every two years for updates to state, federal or CMS contracts and/or requirements. When there is an update, we will publish the most current policy at the provider website.
Code and clinical editing
AMH Health applies code and clinical editing guidelines to evaluate claims for accuracy and adherence to accepted national industry standards and plan benefits. We use sophisticated software products to ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices. Editing sources include but are not limited to CMS National Correct Coding Initiative, Medical Policies and Clinical Utilization Management Guidelines. AMH Health is committed to working with you to ensure timely processing and payment of claims.
The complete set of policies is available at the provider website. If you have questions, please visit the provider self-service website or call the number on the back of the member’s ID card.
December 2019 Anthem Maine Provider News