Starting Oct. 1, 2024, our current ConnectiCare ED Outpatient Facility E/M Coding Reimbursement Policy will expand to include EmblemHealth’s HMO and PPO (non-City of New York) Commercial, Medicare, and Medicaid plans. This policy will apply to all facilities, including freestanding facilities, that submit emergency department (ED) claims with evaluation and management codes (E/M).
We observed a significant number of EmblemHealth claims submitted with codes that lacked evidence to support the level billed. This change will help EmblemHealth pay claims based on coding that accurately reflects the level of care provided to our members.
To implement the new policy, EmblemHealth, like ConnectiCare, will use the Optum Emergency Department Claim (EDC) Analyzer tool™. The EDC Analyzer tool determines the appropriate E/M coding level based on data such as the patient’s presenting problem, diagnostic services performed during the visit, and associated patient comorbidities. To learn more about the EDC Analyzer tool, please visit EDCAnalyzer.com.
Facilities submitting claims for ED E/M codes may experience adjustments to level 2,3, 4, or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial, based on the reimbursement structure within their EmblemHealth contracts. Facilities may submit an appeal request though our provider portal if they believe a higher-level E/M code is justified.
