APG Rate Codes

During 2009, EmblemHealth will begin to pay claims that are billed with Ambulatory Patient Groups (APGs) rate codes (and their corresponding CPT codes) for services covered by APG reimbursement. The APG system is the new state-mandated payment methodology for most Medicaid outpatient services. APGs will be paid for outpatient clinic, ambulatory surgery and emergency department services, when the service is contracted to be reimbursed at the Medicaid rate. APGs will not be used for services that are carved out of Medicaid managed care.

We will follow New York State guidelines for claims submission. New York State has set up the following Web sites to provide information about APGs. Click here for APG rates for Medicaid. For the manual on APGs, please click here.

To facilitate claims processing, we ask that you:

  1. Separate APG and non-APG services onto separate claims;
  2. Report a value code of 24 and an appropriate rate code; and
  3. Report CPT codes for all revenue lines.

Claims without proper coding will be returned to you for correction prior to adjudication.

Planned Hospital Rollout Schedule:
Non-Par Providers: May 15, 2009
GHI HMO and GHI Providers: June 1, 2009
HIP Providers: Staggered rollout to be completed by: September 1, 2009

For information on APGs, go to the New York State Web sites above or you may click here for a discussion of known APG issues or click here for HIPAA APG requirements.