CurrentAnthemPolicy C-20006

Emergency Room Transfers - Facility

Defines Anthem's reimbursement stance when a patient is transferred between outpatient facilities under the same agreement, TIN, or common ownership; affects facility claims for emergency department visits for commercial members.

Policy Summary

PayerAnthem

PolicyEmergency Room Transfers - Facility

Policy CodePolicy C-20006

Change TypeClarified coding descriptions and definition structure

Effective DateJul 17, 2024

Next Review DateN/A

Key ActionSubmit claims with appropriate CPT/HCPCS/revenue codes and supporting medical record documentation following authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

Updated code list descriptions; removed episodes of care from Definition section.

1Emergency room visit reimbursed when transfer occurs between facilities under same TIN/ownership

0Separate reimbursement to transferring facility

5Listed ED E/M CPT codes referenced

07/17/2024Effective / Last approval date

Facility Emergency Transfer Reimbursement

Facility emergency transfer reimbursement criteria

Reimbursement rules for transfers between outpatient facilities sharing agreement/TIN/ownership:

Anthem allows reimbursement for one emergency room visit when a patient is transferred between outpatient facilities operating under the same agreement, with the same tax identification number (TIN), or under common ownership.

Anthem considers these transfers to be a single episode of care and the transferring facility will not be eligible for separate reimbursement.

Exceptions: Provider, state, federal contracts and/or mandate requirements may indicate otherwise; such requirements take precedence.

Emergency Department E/M CPT Codes

Emergency Department E/M codesCPT

99281	Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
99282	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
99283	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
99284	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
99285	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.

Policy Summary

PayerAnthem

PolicyEmergency Room Transfers - Facility

Policy CodePolicy C-20006

Change TypeClarified coding descriptions and definition structure

Effective DateJul 17, 2024

Next Review DateN/A

Key ActionSubmit claims with appropriate CPT/HCPCS/revenue codes and supporting medical record documentation following authorization and medical necessity guidelines.

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.

Claims Submission and Authorization Requirements

Prior Authorization

Claims Submission and Authorization Requirements

These reimbursement policies are a guide to assist in accurate claims submission and outline the basis for reimbursement if the service is covered by an Anthem member's benefit plan. Services must meet prior authorization (when required), medical necessity guidelines appropriate to the procedure and diagnosis, and the member's contract benefits in effect on the date of service. Follow state and federal law and contract language (including definitions, inclusions/exclusions) which take precedence over this Reimbursement Policy. Reimbursement Policy is subject to periodic review and update; Anthem reserves the right to recoup or recover claim payments to the effective date when implementation delays occur.

Use industry-standard, compliant codes on all claim submissions (CPT, HCPCS, revenue codes).
Ensure billed services are fully supported in the medical record and/or office notes.
Obtain prior authorization when required by the member's benefit plan or policy prior to rendering services.
Verify member eligibility and benefits for the date of service before billing.
Follow applicable coding/billing guidelines and any CMS, state, or contractual mandates that supersede this policy.

Denial Risk

Provider Responsibilities and Potential Actions by Anthem

If appropriate coding/billing guidelines or current reimbursement policies are not followed, Anthem may reject or deny the claim and/or recover and recoup claim payments. Unless otherwise noted, these reimbursement policies apply to both participating and non-participating professional providers and facilities. No part of this publication may be reproduced without permission from Anthem.

Claims must reflect services performed using the correct CPT/HCPCS/revenue codes and be supported by documentation.
Maintain documentation to substantiate medical necessity, level of service, and any prior authorization.
Anthem may recoup payments if services do not meet policy or contractual requirements.

Definitions and Policy Principles

Emergency Services — definition

TermEmergency Services

DefinitionA medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson with average knowledge of health and medicine could reasonably expect that absence of immediate medical care could result in: (a) placing the health of an individual in serious jeopardy; (b) serious impairment to bodily function; (c) serious dysfunction of any bodily organ or part; (d) serious disfigurement; or (e) in the case of a pregnant woman, serious jeopardy to the health of the woman or her unborn child.

Source noteDefinition text taken verbatim from policy Definitions section.

General Reimbursement Policy principles

Guidance purposeReimbursement policies serve as a guide to assist in accurate claims submission and outline the basis for reimbursement under a member's benefit plan.

Medical necessity & authorizationServices must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Billing requirementsProviders must follow proper billing/submission guidelines using industry-standard CPT, HCPCS and/or revenue codes fully supported in the medical record or office notes.

ConsequencesIf coding/billing guidelines or reimbursement policies are not followed, Anthem may reject or deny claims and may recover or recoup payments.