CurrentAnthemPolicy C-13001

Emergency Department: Leveling of Evaluation and Management Services - Facility

Defines how the health plan determines and reimburses facility Emergency Department (ED) Evaluation and Management (E/M) code levels based on intensity/complexity of resources and interventions used during the ED encounter; applies to facilities submitting ED claims to Anthem where state, federal, or contract requirements do not supersede.

Policy Summary

PayerAnthem

PolicyEmergency Department: Leveling of Evaluation and Management Services - Facility

Policy CodePolicy C-13001

Change TypeClarified coding and definitionstitle updated

Effective DateJul 1, 2024

Next Review Date

Key ActionThe health plan may request documentation supporting the billed ED E/M level and may deny the claim, adjust reimbursement to a lower classification, or recover overpayments if the billed level is not supported.

SourceLink

POLICY UPDATE CHANGES

Updated coding section and Definitions section; updated title of policy from Facility Emergency Department.

07/01/2024policy effective date

04/01/2024last approval/review date

3 listedexplicit exclusions from ED leveling

ACEP, EMTALA, Optumsource materials considered

Facility Emergency Department (ED) E/M Reimbursement Criteria

Facility ED E/M reimbursement criteria

Coverage and application rules for facility ED E/M services:

Facility ED services are reimbursable when provided for emergency services unless provider, state, federal, or contract requirements indicate otherwise.

The health plan determines the ED E/M level by classifying the intensity and/or complexity of facility resources or interventions utilized to furnish all services indicated on the claim; providers must use appropriate HIPAA-compliant codes.

ALL of the following

ONE OR MORE OF
- Deny the claim and request resubmission at the appropriate level or request the provider to submit documentation supporting the level billed.

Policy Summary

PayerAnthem

PolicyEmergency Department: Leveling of Evaluation and Management Services - Facility

Policy CodePolicy C-13001

Change TypeClarified coding and definitionstitle updated

Effective DateJul 1, 2024

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Documentation and Claim Adjustment Requirements

Documentation Required

Documentation requests and claim adjustments — Health plan may request documentation; possible denial or adjustment if billed level not supported

The health plan may request medical record documentation to support the Emergency Department (ED) Evaluation and Management (E/M) level billed. If the documentation does not support the level billed, the plan may deny the claim, require resubmission at the appropriate level, adjust reimbursement to reflect the supported ED E/M classification, and/or recover and/or recoup payments made in excess of the supported level. Providers must submit complete, accurate, and HIPAA-compliant codes for all services rendered during the ED encounter and retain records sufficient to justify the billed level. Timely response to documentation requests is required; failure to provide requested documentation may result in adverse claim action.

Provider must use appropriate HIPAA-compliant CPT/HCPCS/revenue codes for all ED services billed.
Health plan may request documentation to support the ED E/M level billed.
If documentation does not support the billed level, the plan may: deny the claim and request resubmission at the appropriate level; adjust reimbursement to the supported ED E/M classification; and/or recover/recoup overpayments.
Providers should retain and submit medical records/office notes that fully substantiate the services and level billed.
Timely responses to documentation requests are required to avoid claim denial or adjustment.

Key Definitions

Interventions

DefinitionInterventions = The staff the facility utilizes, and the work they perform.

ExclusionProfessional provider services are not considered facility interventions or facility resources.

Claim relevanceInterventions reported on the claim are used to classify ED E/M level (type and amount of staff work informs intensity/complexity).

Resources

DefinitionResources = Facility building, equipment, and/or supplies utilized.

Role in levelingResources indicated on the claim are included in the health plan's assessment of ED E/M intensity/complexity.

DistinctionResources are facility assets; professional provider services are not counted as facility resources.

Intensity and/or Complexity

DefinitionIntensity and/or Complexity = The quantity, type, or specialization of interventions and/or resources used and the nature of the presenting problem, member age, acuity, and diagnostic services performed, as indicated on the claim.

FunctionUsed by the health plan to classify the ED E/M code level for reimbursement.

Data sourceDetermination is based on what is reported on the claim (interventions, resources, diagnostics, acuity, and member factors).

Emergency Services

DefinitionEmergency Services = A medical condition with acute symptoms of recent onset and sufficient severity that a prudent layperson could reasonably expect lack of immediate medical care to result in serious jeopardy, serious impairment or dysfunction, serious disfigurement, or (for a pregnant woman) jeopardy to the woman or unborn child.

Standard invokedPrudent layperson standard (average knowledge of health and medicine) determines whether symptoms meet emergency criteria.

Policy implicationFacility ED services meeting this definition are eligible for reimbursement per policy unless superseded by other requirements.

OpenPayer

Emergency Department: Leveling of Evaluation and Management Services - Facility

Facility Emergency Department (ED) E/M Reimbursement Criteria

ED E/M Codes and Determination Basis

Documentation and Claim Adjustment Requirements

Key Definitions