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Payment Policy changes for 1/1/2020

Date: 12/03/19

Ambetter from MHS is publishing its Payment Policies to inform providers about acceptable billing practices and reimbursement methodologies procedures and services. Ambetter from MHS believes that publishing this information will help providers to bill claims more efficiently, therefore reducing unnecessary denials and delays in claims processing and payments.

We will apply these policies as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that Ambetter from MHS currently employs.

These policies are developed based on medical literature and research, industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state or Ambetter from MHS regulations.

Visit to find the Payment Policies. The effective date for the below policies is January 1, 2020. We have adopted the following payment policies:

Policy Name


Activation Date

Products Impacted

Non-adherence Consequence

PROM Testing


The purpose of this policy is to define medical necessity criteria for the non-invasive testing for rupture of fetal membranes testing (e.g. AmniSure®, Actim® PROM and the ROM Plus Fetal Membranes Rupture Test) for the diagnostic evaluation of premature rupture of membranes.


Ambetter from MHS

It is the policy of health plans affiliated with Centene Corporation that non-invasive testing for rupture of fetal membranes are considered not medically necessary for members, as it has not been shown to improve clinical outcomes over standard methods of diagnosis. Claims billed with CPT 84112 will always deny with EXxP.

(EOP) Description

EXxP- Service will deny according to a payment or clinical policy.  

30 Day Readmission


The purpose of this policy is to promote more clinically effective, cost efficient and improved health care through appropriate and safe hospital discharge of patients.


Ambetter from MHS

For a readmission that is determined to have been inappropriate or preventable according to the clinical review guidelines. The Health Plan will deny payment or reimbursement with EXym, which advises the provider to submit medical records. If medical records for both the original and subsequent admission are not received, the second claim denial will be upheld with EX code EXym.

(EOP) Description

EXym- Potential preventable readmission submit all medical records

Problem Oriented Visits with Preventative Visits

The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventative visits to be used in making payment decisions and administering benefits.  Use of modifier 25 will be paid at 50% of fee schedule.  This stems from additional resources are not directly consumed during the provision of the service.



Ambetter from MHS

Claim will pend for clinical review of codes billed. If claim is appropriately billed, the preventative medicine code will reimburse at 100% of the fee schedule and the problem-oriented code will reimburse at 50% of the fee schedule.

(EOP) Description

EXpB – reimbursement reduction based on payment policy. See plan website.

To view the actual policies, please visit the MHS Provider Portal or call MHS Provider Relations at 1-877-647-4848 and ask for a copy. Thank you for being our partner in care.