AmeriHealth Closes Pathology Network for New Office-Based Pathology Providers

January 2018 ~

AmeriHealth posted a notice in early December, notifying providers and consumers that the insurer’s pathology provider network will be closed for new office-based pathology providers, effective January 1st, 2018.

This policy change will apply to pathologists in the AmeriHealth service area (i.e., participating counties in New Jersey, Pennsylvania, Delaware, and Maryland) except for pathology providers joining an existing participating hospital-based pathology group in a participating hospital in the identified service area.

These changes affect the credentialing of office-based pathology providers and the following HMO and PPO claim payment policies:

HMO Policy

“Effective April 1st, 2018, AmeriHealth will not reimburse for pathology services according to the existing Claim Payment Policy #00.03.07t: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products. Claims submitted for pathology services that are billed by an office-based pathologist on or after April 1, 2018, will be denied consistent with this policy.”

 PPO Policy

“Effective April 1st, 2018, AmeriHealth will update Claim Payment Policy #00.01.25aq: PPO Network Rules for Provision of Specialty Service for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services to prohibit billing and reimbursement for pathology services provided by office-based pathologists for PPO members.”

The insurer says the decision to make this follows an in-depth analysis and review of AmeriHealth’s HMO and PPO laboratory network and current policies. AmeriHealth states the changes will help to reduce out-of-pocket expenses for our members, as well as ensure consistency with industry standards and practices.

For more information on these changes, see the view this existing HMO policy, here, and view the updated PPO policy, here.



Source(s): AmeriHealth Provider News Center; AmeriHealth Provider News Center;