RetiredCareSourcePolicy N/A

Discharge Against Medical Advice (AMA) reimbursement

Defines CareSource's reimbursement stance and administrative requirements when a member leaves a hospital or acute care setting against medical advice; applies to CareSource Arkansas PASSE claims and providers submitting related claims.

Policy Summary

PayerCareSource

PolicyDischarge Against Medical Advice (AMA) reimbursement

Policy CodePolicy N/A

Change TypeNo material change / archival

Effective DateJul 1, 2022

Next Review Date

Key ActionClaims are subject to retrospective review and reimbursement may be adjusted; if a member leaves AMA in the ER and an inpatient review was submitted, only the ER will be considered for payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

06/30/2023policy archival date

07/01/2022effective period start

12/16/2020; 02/04/2022issue/revision history

AR PASSEprogram scope

Discharge Against Medical Advice (AMA) — Coverage Criteria

AMA coverage criteria

Reimbursement principles when a member leaves against medical advice (AMA):

Payment considered only for services, procedures, and supplies actually rendered.

The discharge status code on the submitted claim must indicate that the member left against medical advice.

If a member leaves AMA in the emergency room and the facility submitted a medical necessity review for inpatient services, only the emergency room will be considered for payment.

Claims are subject to retrospective review; CareSource reserves the right to adjust reimbursement in accordance with this policy.

Member must be eligible at the time the service, procedure, or supply was provided, and the service, procedure, or supply must be a covered benefit.

Policy Summary

PayerCareSource

PolicyDischarge Against Medical Advice (AMA) reimbursement

Policy CodePolicy N/A

Change TypeNo material change / archival

Effective DateJul 1, 2022

Next Review Date

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.

Claim Coding and Submission Requirements

Claim submission requirementsmixed

No codes listed

Eligibility and coverage requirement

Eligibility at time of serviceMember must be eligible at the time the service, procedure, or supply was provided.

Covered benefit requirementThe service, procedure, or supply must be a covered benefit for reimbursement to be considered.

Coding and submissionReimbursement depends on submitting approved HCPCS and CPT codes with appropriate modifiers, if applicable.

Medical necessity reviewsMedical necessity reviews do not guarantee reimbursement; all services are subject to review for medical necessity.

Retrospective reviewClaims are subject to retrospective review and CareSource may adjust reimbursement per policy.

Reimbursement Rules and Provider Responsibilities

Denial Risk

Reimbursement and review rules for AMA discharges

Claims for members who leave against medical advice are subject to retrospective review and reimbursement may be adjusted per policy. If a member leaves AMA in the emergency room and the facility submitted a medical necessity review for inpatient services, only the emergency room will be considered for payment.

CareSource will only pay for services, procedures, and supplies rendered.
The discharge status code on the submitted claim must indicate that the member left against medical advice.
Member must be eligible at time of service and the service must be a covered benefit; submit approved HCPCS and CPT codes with appropriate modifiers.
Medical necessity reviews do not guarantee reimbursement; all services are subject to review for medical necessity.

Key Definitions

Against Medical Advice (AMA)

DefinitionA member chooses to leave the hospital or acute care setting before a practitioner writes the order for discharge.

Discharge status codeThe discharge status code on the submitted claim must indicate that the member left against medical advice.

Payment scope for AMA in EDIf a member leaves AMA in the emergency room and an inpatient medical necessity review was submitted, only the emergency room will be considered for payment.

Payment limitationCareSource will only pay for services, procedures, and supplies actually rendered.

Review and adjustmentClaims for AMA discharges are subject to retrospective review; reimbursement may be adjusted according to policy.