Emergency Services: Non-Participating Providers and Facilities — Reimbursement Policy
Governs reimbursement rules for emergency services provided by nonparticipating providers and facilities for Anthem HealthKeepers Plus (Medicaid) members and other product lines; affects nonparticipating professional providers and facilities billing Anthem HealthKeepers Plus members.
09/06/2024 policy review completed with no material changes.
Emergency Services Reimbursement Criteria
Emergency services reimbursement criteria
Reimbursement policy and applicable bases:
ALL of the following
Reimbursement basis
- For Medicaid product lines: reimbursement is the amount that would have been reimbursed to the provider according to Virginia's State Fee-for-Service (FFS) Medicaid Program.
- For all other product lines: reimbursement is the applicable out-of-network emergency rate for nonparticipating providers and facilities.
- Provider and payer actions adhere to EMTALA and Federal Medicaid Managed Care Regulations.
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.