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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyAmeriHealth LA Non-Covered Coverage | OpenPayer
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    CurrentAmeriHealth Caritas LouisianaPolicy CCP.4019

    Non-Covered Benefits

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    This policy governs AmeriHealth Caritas Louisiana coverage and reimbursement determinations for excluded, limited, improperly billed, or otherwise non-covered services for participating providers, facilities, and Medicaid recipients in Louisiana.

    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyNon-Covered Benefits
    Policy CodePolicy CCP.4019
    Change TypeNo material change
    Effective DateN/A
    Last ReviewMar 1, 2021
    Next Review DateMarch 1, 2023
    Key ActionDocument services actually rendered because undocumented services may be subject to recoupment.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6Policy topic categories
    3Never-event scenarios
    3 yearsNew-patient lookback
    NoPrior authorization for medically necessary outpatient visits
    Under 21

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    Outpatient visit limitation age threshold

    Non-Covered Services and Coverage Rules

    Not Medically Necessary / Excluded Services

    Services are excluded from Medicaid coverage and deemed not medically necessary when they are not approved by the Food and Drug Administration or are experimental, investigational, or cosmetic.

    ANY of the following

    • The service is not approved by the Food and Drug Administration.
    • The service is experimental or investigational.
    • The service is cosmetic.

    Aborted Surgical Procedures

    Medicaid will not pay charges for an aborted surgical procedure, regardless of the reason.

    ALL of the following

    • The billed service is associated with an aborted surgical procedure.
    • The charge is for professional, operating room, or anesthesia services.

    Never Events

    Medicaid will not pay for never events or medical procedures performed in error that are preventable and have a serious, adverse impact on the Medicaid recipient.

    ANY of the following never events

    • The wrong surgical procedure is performed on the recipient.
    • A surgical or invasive procedure is performed on the wrong body part.
    • A surgical or invasive procedure is performed on the wrong recipient.

    Infertility Services

    Infertility services are excluded when the service is intended to diagnose or correct infertility or to enhance reproductive capacity.

    ANY of the following

    • The service is for diagnosis of infertility.
    • The service is for correction or treatment of infertility.
    • The service is a sterilization reversal procedure.
    • The primary purpose of a surgical, laboratory, or radiological service is to enhance reproductive capacity.

    Pain Management

    Coverage depends on the indication for the pain-management service.

    Coverage or exclusion applies when ANY of the following is true

    • An epidural injection of an anesthetic substance is provided to prevent or control acute pain, such as pain occurring during delivery or surgery.

      This indication is covered.

    • An epidural injection is billed for pain management, pain control, or any reason other than prevention or control of acute pain.

      Not covered.

    • A spinal injection is provided to alleviate chronic, intractable pain.

      Not covered.

    • The service is provided for chronic pain management.

      Not covered.

    Outpatient Visit Services

    Outpatient visit services are covered when medically necessary. Prior authorization is not required for reimbursement.

    ALL of the following

    • The outpatient visit or service is medically necessary.
    • The service is provided in an emergency room, outpatient hospital clinic, physician's office, Federally Qualified Health Center, Rural Health Center, or another eligible outpatient setting.
    • All visits and services provided are medically necessary.

      There is no limit on covered outpatient visits; recipients under 21 are not subject to program limitations.

    • Prior authorization is not required for reimbursement.

      The service must still meet medical-necessity requirements.

    Physicians and all other professionals must abide by the professional guidelines established by their certifying and licensing agencies in addition to complying with AmeriHealth Caritas Louisiana regulations. In general, services that are not approved by the Food and Drug Administration or that are experimental, investigational, or cosmetic are excluded from Medicaid coverage and are deemed not medically necessary.

    Providers shall not bill Medicaid or the recipient for a missed appointment or any other service that was not actually provided. Services that have not been documented are considered services not rendered and are subject to recoupment.

    Medicaid will not pay professional, operating room, or anesthesia charges for an aborted surgical procedure, regardless of the reason.

    Medicaid will not pay for never events or medical procedures performed in error that are preventable and have a serious, adverse impact on the health of the Medicaid recipient. Reimbursement will not be provided when the wrong surgical procedure is performed on a recipient, a surgical or invasive procedure is performed on the wrong body part, or a surgical or invasive procedure is performed on the wrong recipient.

    AmeriHealth Caritas Louisiana does not reimburse for services related to a non-covered service. Any payment received for non-covered and related services is subject to post-payment review and recovery.

    AmeriHealth Caritas Louisiana does not pay for services relating to the diagnosis or correction of infertility, including sterilization reversal procedures. This exclusion extends to any surgical, laboratory, or radiological service when the primary purpose is to diagnose infertility or to enhance reproductive capacity.

    AmeriHealth Caritas Louisiana covers the epidural injection of an anesthetic substance for the prevention or control of acute pain, such as pain occurring during delivery or surgery. Billing these procedures subsequently for pain management, pain control, or any other reason is not covered. Medicaid does not cover spinal injections to alleviate chronic, intractable pain, and AmeriHealth Caritas Louisiana does not cover any services for chronic pain management.

    Services that are not approved by the Food and Drug Administration, or that are experimental, investigational, or cosmetic, are excluded from Medicaid coverage and will be deemed not medically necessary.

    Provider Billing and Documentation Requirements

    Prior Authorization

    Medically Necessary Outpatient Visits Do Not Require Prior Authorization

    Medically necessary outpatient visits and services are covered without a prior authorization requirement. This applies to professional services provided in emergency rooms, outpatient hospital clinics, physician offices, FQHCs, and RHCs; outpatient visit services have no limit, and recipients under age 21 are not subject to program limitations.

    • All visits and services must be medically necessary.
    • No prior authorization is required for reimbursement of medically necessary outpatient visits and services.
    Documentation Required

    Document Services Rendered

    Bill only for services actually rendered and maintain sufficient documentation to support each billed service. Services that are not documented are considered not rendered and may be subject to recoupment.

    • Do not bill Medicaid or the recipient for missed appointments or other services not actually provided.

    Policy Context

    This policy is primarily an administrative coverage and billing policy, rather than a condition-specific clinical policy. It addresses excluded or non-medically necessary services, preventable surgical errors, infertility-related services, chronic pain management, and outpatient visit reimbursement. Clinical treatment decisions remain the responsibility of the treating provider, while coverage determinations also depend on plan benefits and applicable state and federal requirements.

    Key Terms

    Never event
    DefinitionA preventable medical procedure performed in error that has a serious, adverse impact to the health of the Medicaid recipient.
    Example 1The wrong surgical procedure is performed on a recipient.
    Example 2A surgical or invasive procedure is performed on the wrong body part.
    Example 3A surgical or invasive procedure is performed on the wrong recipient.
    New patient
    DefinitionA patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.
    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyNon-Covered Benefits
    Policy CodePolicy CCP.4019
    Change TypeNo material change
    Effective DateN/A
    Last ReviewMar 1, 2021
    Next Review DateMarch 1, 2023
    Key ActionDocument services actually rendered because undocumented services may be subject to recoupment.
    SourceLink
    On This Page
    Non-Covered Services and Coverage RulesProvider Billing and Documentation RequirementsPolicy ContextKey Terms
  1. Ensure documentation supports the services billed.
    2. Denial Risk

    Unapproved, Experimental, Investigational, or Cosmetic Services

    Services not approved by the Food and Drug Administration, or services that are experimental, investigational, or cosmetic, are excluded from Medicaid coverage and will be deemed not medically necessary. These services are at risk for denial.

    • Verify that services are approved, medically necessary, and within covered benefits before providing and billing them.
    • Cosmetic services are excluded from coverage.
    Denial Risk

    Aborted Surgical Procedures

    Medicaid will not pay professional, operating room, or anesthesia charges for an aborted surgical procedure, regardless of the reason for the abortion of the procedure.

    • Professional charges are not payable.
    • Operating room charges are not payable.
    • Anesthesia charges are not payable.
    Billing Rule

    Services Not Provided or Documented

    Do not bill Medicaid or the recipient for a missed appointment or any other service that was not actually provided. Services that have not been documented are considered services not rendered and are subject to recoupment.

    • Bill only services actually provided.
    • Maintain documentation supporting every billed service.
    • Undocumented services may result in recovery of payment.
    Denial Risk

    Never Events Are Not Reimbursable

    Medicaid will not pay for preventable medical procedures performed in error that have a serious, adverse impact on a Medicaid recipient. Reimbursement is not provided for these never events.

    • The wrong surgical procedure is performed on a recipient.
    • A surgical or invasive procedure is performed on the wrong body part.
    • A surgical or invasive procedure is performed on the wrong recipient.
    Denial Risk

    Services Related to Non-Covered Services

    AmeriHealth Caritas Louisiana does not reimburse services related to a non-covered service. Any payment received for the non-covered service and related services is subject to post-payment review and recovery.

    • Identify non-covered services before related services are provided or billed.
    • Payments for related services may be recovered after payment.
    Denial Risk

    Infertility Services

    Services relating to the diagnosis or correction of infertility are not covered, including sterilization reversal procedures. The exclusion applies when the primary purpose of a surgical, laboratory, or radiological service is to diagnose infertility or enhance reproductive capacity.

    • Diagnostic infertility services are excluded.
    • Corrective infertility services are excluded.
    • Sterilization reversal procedures are excluded.
    • Related surgical, laboratory, and radiological services are excluded when primarily intended to diagnose infertility or enhance reproductive capacity.
    Denial Risk

    Chronic Pain Management

    AmeriHealth Caritas Louisiana does not cover services for chronic pain management, including spinal injections to alleviate chronic, intractable pain. An epidural injection of an anesthetic substance is covered only for acute pain prevention or control, such as during delivery or surgery; billing that procedure subsequently for pain management, pain control, or another reason is not covered.

    • Chronic pain management services are not covered.
    • Spinal injections for chronic, intractable pain are not covered.
    • Acute-pain epidural injections during delivery or surgery may be covered when otherwise eligible.
    • Do not subsequently bill an acute-pain epidural injection for pain management, pain control, or another non-covered reason.
    Billing Rule

    FQHC and RHC Billing

    FQHCs and RHCs are reimbursed for covered Medicaid services under the all-inclusive Prospective Payment System (PPS) specified under Section 1902(bb) of the Social Security Act. PPS payments include professional charges and must be billed by the facility using its provider ID and Tax Identification Number (TIN).

    • Bill applicable services under the FQHC or RHC facility provider ID.
    • Use the facility's TIN.
    • Professional services performed in an FQHC or RHC may be recouped if billed under an individual physician or practitioner Medicaid number.
    Lookback period
    Three years.
    ExceptionThe initial prenatal visit of each new pregnancy.