CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Emergency Department Waiver of Copayment

Defines when the member copayment for Emergency Department (ED) services is waived for BlueCHiP for Medicare and Commercial plans; plan deductibles still apply and certain ancillary service copays (e.g., MRI/MRA) remain applicable.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Emergency Department Waiver of Copayment

Policy CodePolicy N/A

Change Typeclarified

Effective DateJan 1, 2015

Next Review Date

Key ActionDocument timing of hospital admission relative to ED treatment (within 24 hours) or observation admission status, or DOA/expiration in ED to support copayment waiver.

SourceLink

POLICY UPDATE CHANGES

Policy documents when the copayment for an emergency room visit is waived; plan deductibles still apply.

2Plan types referenced

24Admission window (hours)

3Waiver events listed

Policy summary

Policy purpose: documents when the copayment for an emergency room visit is waived. Definition: an Emergency Department is an organized hospital-based facility providing unscheduled episodic services for immediate medical attention and the facility must be available 24 hours a day. Plan applicability: the waiver rules apply to BlueCHiP for Medicare and Commercial plans. Note that plan deductibles still apply, and certain ancillary service copayments (for services not included in ER reimbursement, e.g., MRI/MRA) remain applicable.

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When the ED copayment is waived

BlueCHiP for Medicare - Copayment Waiver Criteria

A member's copayment for Emergency Department Services is waived if ONE of the following conditions is met:

ANY of the following

The member is admitted to the hospital within 24 hours of treatment in the emergency department.within 24 hours of ED treatment
The member is dead on arrival (DOA) to the emergency department or expires in the emergency department.

Commercial - Copayment Waiver Criteria

A member's copayment for Emergency Department Services is waived if ONE of the following conditions is met:

ANY of the following

The member is admitted to the hospital within 24 hours of treatment in the emergency department.within 24 hours of ED treatment
The member is admitted to the hospital under an OBSERVATION status.
The member is dead on arrival (DOA) to the emergency department or expires in the emergency department.

No clinical criteria or prior authorization requirements are specified; the policy applies to BlueCHiP for Medicare and Commercial with slightly different qualifying events. Policy documents when the copayment for an emergency room visit is waived; plan deductibles still apply.

Documentation and billing implications

Documentation Required

Document hospital admission timing/status

Document the timing of hospital admission relative to ED treatment to support a copayment waiver — specifically note if the member was admitted to the hospital within 24 hours of ED treatment, admitted under observation status (when applicable), or was dead on arrival (DOA) or expired in the ED.

Billing Rule

Ancillary service copays apply

Note that services not included in ER reimbursement (for example, MRI or MRA) retain their applicable copays even when the ED copayment is waived.

Document changes

2015-01-01effective_date

Policy effective date: Medical Coverage Policy for Emergency Department Waiver of Copayment became effective.

2018-05-01last_reviewLatest

Policy last updated/reviewed on this date.

policy_change_clarified

Policy clarifies when the copayment for an emergency room visit is waived; plan deductibles still apply. No clinical criteria or prior authorization requirements specified; applies to BlueCHiP for Medicare and Commercial with slightly different listed qualifying events.

criteria_medicaid_medicare

BlueCHiP for Medicare: Copayment waived if member is admitted to hospital within 24 hours of ED treatment, or is dead on arrival (DOA) or expires in the ED.

criteria_commercial

Commercial: Copayment waived if member is admitted to hospital within 24 hours of ED treatment, admitted under observation status, or is dead on arrival (DOA) or expires in the ED.