Provider Manual Update - Providers – Amerigroup

Provider Manual Update
Potentially Preventable Readmissions
and Potentially Preventable Complications
Summary: This serves as an update to the Amerigroup* Medicaid/CHIP Provider Manual
related to potentially preventable readmissions (PPR) and potentially preventable
complications (PPC).
 What this means to you: Effective March 1, 2013, PPR was implemented in feefor-service and managed care (STAR and STAR+PLUS). Effective March 1, 2014, PPC was
included as well for Medicaid (STAR and STAR+PLUS). Lastly, effective
September 1, 2014, CHIP was included in PPR and PPC. Applicable reductions were
applied to affected hospitals.
The Texas Health and Human Services Commission (HHSC) is directed by SB 7 to
establish quality-based measurements and payment systems in both fee-for-service and
managed care. HHSC is incorporating the PPR and PPC payment adjustments in the
managed-care context through its contracts with managed-care organizations. PPR and
PPC uses encounter submissions for fee-for-service, Medicaid managed care, family
planning Title XIX, and managed care encounters. These encounters are used to
determine quality performance. PPR and PPC reductions are applied regardless of
payment methodology and apply to hospitals including behavioral health hospitals.
Amerigroup receives hospital lists and effective periods from HHSC related to PPR and
PPC performance with data applicable to the reduction. Upon receipt, Amerigroup will
implement and apply those reductions for each hospital including behavioral health
hospitals within the list. Amerigroup notifies hospitals within the list provided by HHSC,
in writing, of the applicable reductions; however, this notice serves as the provider
manual update. As a payer of last resort, overpayments are subject to recovery and/or
Additional information related to potentially preventable events can be found on the
Texas Medicaid Healthcare Partnership website at
What if I need assistance?
If you have questions about this communication, received this fax in error or need
assistance with anything else, contact your local Provider Relations representative or
call Provider Services toll free at 1-800-454-3730.
*In Texas, Amerigroup members in the Medicaid Rural Service Area are served by Amerigroup Insurance
Company; all other Amerigroup members are served by Amerigroup Texas, Inc.
Issued January 2015