Emergency Services: Non-Participating Providers and Facilities, Reimbursement Policy
Governs reimbursement rules for emergency services provided by non-participating professional providers and facilities to Anthem Medicare Advantage members, including adherence to EMTALA and Medicare-based reimbursement unless superseded by contract or regulation.
Reimbursement is based on no more than the amount that would have been reimbursed to the provider if the beneficiary were enrolled in original Medicare.
Affirms adherence to EMTALA and states reimbursement will not be limited by lists of diagnoses or symptoms.
Lists related internal Anthem reimbursement policies that apply to emergency service claims (Eligible Billed Charges, Code and Clinical Editing Guidelines, Claims Requiring Additional Documentation).
Reimbursement for Non-Participating Emergency Services
Reimbursement criteria for non-participating emergency services
Anthem Medicare Advantage reimburses emergency services provided by nonparticipating providers and facilities when the following conditions are met:
ALL of the following
- Reimbursement is allowed unless provider, state, federal, or CMS contracts or requirements indicate otherwise.
- Reimbursement amount is limited to no more than the amount that would have been reimbursed under original Medicare unless otherwise required by federal regulation or contract.
- Anthem Medicare Advantage adheres to EMTALA; reimbursement will not be limited by predefined lists of diagnoses or symptoms.
- Additional medical record documentation may be requested to clearly identify and determine appropriate reimbursement of emergency services.
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