CurrentBlue Cross Blue Shield - WisconsinPolicy C-20006

Emergency Room Transfers - Facility

Defines reimbursement for emergency room visits when a patient is transferred between outpatient facilities under common ownership, same TIN, or same agreement; applies to commercial facility claims under the payer's reimbursement policies.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyEmergency Room Transfers - Facility

Policy CodePolicy C-20006

Change TypeNo material change

Effective DateJul 17, 2024

Next Review DateN/A

Key ActionFollow proper billing and submission guidelines; bill one ER visit when transfer is between facilities under same agreement/TIN/common ownership and do not seek separate reimbursement for the transferring facility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1ER visit reimbursed when transfer within same agreement/TIN/common ownership

0Transferring facility separate reimbursement

5Related ED E/M codes listed

ME, NHMarkets exempt

07/17/2024Effective date

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyEmergency Room Transfers - Facility

Policy CodePolicy C-20006

Change TypeNo material change

Effective DateJul 17, 2024

Next Review DateN/A

SourceLink

On This Page

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Emergency Room Transfer Coverage Criteria

Reimbursement stance for emergency room transfers between facilities:

When a patient is transferred between outpatient facilities operating under the same agreement, with the same tax identification number (TIN), or under common ownership, the Health Plan allows reimbursement for one emergency room visit and considers the transfer a single episode of care; the transferring facility is not eligible for separate reimbursement.

This policy applies unless provider, state, federal contracts and/or mandate requirements indicate otherwise.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; providers must follow proper billing and submission guidelines and use industry-standard, compliant CPT/HCPCS/revenue codes fully supported by the medical record. Failure to follow coding/billing guidelines may result in claim rejection, denial, or recoupment.

Related Emergency Department Codes

Related 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.

Billing and Reimbursement Rules

Billing Rule

Billing, Authorization, and Reimbursement Rules for ER Transfers

Follow the plan's billing, authorization, and medical necessity requirements when submitting claims for emergency room visits that involve transfer between outpatient facilities; use industry‑standard CPT/HCPCS/revenue codes supported by the medical record. When a patient is transferred between outpatient facilities operating under the same agreement, same TIN, or under common ownership, the Health Plan allows reimbursement for one ER visit and treats the transfer as a single episode of care — the transferring facility is not eligible for separate reimbursement. Failure to follow coding/billing or authorization guidance may result in claim rejection, denial, or recovery/recoupment.

Use compliant CPT, HCPCS and/or revenue codes supported by medical records and office notes (per standard billing submission rules).
Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.
If coding/billing or reimbursement policies are not followed, the plan may reject or deny the claim and recover/recoup payment.
One ER visit is reimbursed when transfer is between outpatient facilities under the same agreement, same TIN, or common ownership; the transferring facility is not eligible for separate reimbursement.

Definitions and Policy Terms

Emergency Services — definition

TermEmergency Services

ApplicationUsed to determine when emergency evaluation and treatment meet criteria for coverage and reimbursement under this policy.

Reimbursement Policy / Billing Requirements

Billing RequirementsProviders must follow proper billing and submission guidelines and use industry-standard, compliant codes (CPT, HCPCS, and/or revenue codes) on all claim submissions; billed services must be fully supported in the medical record and/or office notes.

ConsequencesFailure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial and/or recovery/recoupment of claim payment.