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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAmeriHealth Caritas VIP Care ASC Update | OpenPaye…
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    CurrentAmeriHealth Caritas VIP CarePolicy RPC.0036.FLDS

    Ambulatory Surgery Center Reimbursement Policy

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    This policy governs allowable facility services and reimbursement for procedures performed in an ambulatory surgery center, including payment reductions, prior authorization, and claim submission requirements.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyAmbulatory Surgery Center Reimbursement Policy
    Policy CodePolicy RPC.0036.FLDS
    Change TypeMaterial update
    Effective DateN/A
    Last ReviewAug 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization for an ASC procedure before the service is performed.
    SourceLink
    POLICY UPDATE CHANGES

    The July 2026 biennial review added a Place of Service definition and policy requirement.

    The September 2026 revision removed the next review date.

    The September 2026 revision replaced the plan name with the term 'the health plan.'

    100%Highest-paying procedure payment
    50%Additional applicable procedure payment
    50%Terminated procedure payment
    POS 24

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Required place of service
    RequiredASC prior authorization

    ASC Facility Reimbursement Requirements

    ASC Reimbursement Requirements

    ASC facility reimbursement is subject to all of the following payment and claim conditions:

    ALL of the following

    • The service is an ASC procedure or service billed for facility reimbursement.
    • Prior authorization is obtained before the ASC procedure is performed.
    • The claim is submitted with Place of Service 24.
    • For multiple surgical procedures performed in the same operative session and subject to the multiple-procedure discount, payment is 100% of the highest-paying surgical procedure plus 50% of the applicable payment rate for each other ASC-covered surgical procedure subject to the discount.
    • If a surgical procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room, but before anesthesia has been induced or the procedure initiated, payment is 50% of the rate.
    • A service considered non-covered by the health plan is denied payment.

    Services Included in the Facility Fee

    The ASC facility fee includes all of the following services and supplies directly related to the surgical service:

    ALL of the following

    • Nursing, technician, and related services.
    • Use of the facility.
    • Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment directly related to the provision of surgical services.
    • Administrative, recordkeeping, and housekeeping items and services.
    • Materials for anesthesia.

    Payment Reduction and Claim Coding

    Multiple surgical procedures in one operative sessionmixedCovered
    No codes listed
    Terminated surgical procedure after preparation and transport to the operating room but before anesthesia or procedure initiationmixedCovered
    No codes listed
    Bilateral surgical proceduresModifierCovered
    No codes listed
    Place of Service 24RevenueCovered
    24Freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis
    Highest-Paying Procedure
    Unit of paymentThe individual surgical procedure
    Highest-paying procedurePaid at 100% of the highest-paying surgical procedure on the claim
    Applicable sessionMultiple surgical procedures furnished in the same operative session and subject to the multiple-procedure discount
    Additional Procedures
    Additional procedure rate50% of the applicable payment rate
    Procedures affectedEach other ASC-covered surgical procedure subject to the multiple-procedure discount

    Provider Billing and Authorization Actions

    Prior Authorization

    Prior authorization required

    Obtain prior authorization for an ASC procedure before the service is performed.

    Denial Risk

    Non-covered ASC services may be denied

    A claim for a service considered non-covered by the health plan will be denied payment.

    Key Terms

    Ambulatory Surgery Center (ASC)
    Certification and ownershipA certified ambulatory surgical center may be either hospital-operated or independent
    Hospital-operated ASCMust be a separately identified entity, physically and administratively distinct from the hospital's other inpatient operations
    Medicare surgery limitationMay not provide surgery to a Medicare patient when an overnight hospital stay is anticipated before surgery
    Transfer capabilityMust be able to provide immediate transfer to a hospital when hospitalization after surgery is warranted
    Place of Service (POS) 24
    Facility typeA freestanding facility
    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyAmbulatory Surgery Center Reimbursement Policy
    Policy CodePolicy RPC.0036.FLDS
    Change TypeMaterial update
    Effective DateN/A
    Last ReviewAug 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization for an ASC procedure before the service is performed.
    SourceLink
    On This Page
    ASC Facility Reimbursement RequirementsPayment Reduction and Claim CodingProvider Billing and Authorization ActionsKey Terms
    Timing requirementThe procedures are furnished in the same operative session
    Bilateral Procedure Reduction
    ReductionA 50% multiple-procedure reduction applies
    Procedures affectedAll bilateral procedures subject to multiple-procedure discounting
    Bilateral sessionThe procedure is performed bilaterally in one operative session
    Terminated Procedure Payment
    Payment rate50% of the rate
    Reason for terminationThe surgical procedure is terminated due to the onset of medical complications
    Required point in the procedureAfter the patient has been prepared for surgery and taken to the operating room, but before anesthesia has been induced or the procedure initiated
    Bilateral Procedure Units
    Reporting requirementReport a bilateral procedure as two procedures
    Separate-line methodReport a single unit on two separate claim lines
    Single-line methodReport 2 in the unit field on one claim line
    Billing Rule

    Use Place of Service 24

    Submit claims for ambulatory surgery procedures or services with Place of Service 24 for reimbursement.

    Billing Rule

    Apply multiple-procedure payment reduction

    When multiple surgical procedures are performed in the same operative session and are subject to the multiple procedure discount, report them according to the applicable discount methodology.

    • Payment is 100 percent of the highest-paying surgical procedure on the claim.
    • Payment is 50 percent of the applicable payment rate for each other ASC-covered surgical procedure subject to the multiple procedure discount furnished in the same session.
    Billing Rule

    Report bilateral procedures correctly

    Report a procedure performed bilaterally in one operative session as two procedures when applicable.

    • Submit as a single unit on two separate claim lines, or enter “2” in the unit field on one claim line.
    • The multiple procedure reduction of 50 percent applies to all bilateral procedures subject to multiple procedure discounting.
    Exclusion
    Other than a physician's office
    Services providedSurgical and diagnostic services provided on an ambulatory basis