CurrentEmpire BluecrossPolicy 6-06092

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 in listed states; establishes basis for payment and documentation expectations.

Policy Summary

PayerEmpire Bluecross

PolicyEmergency Services: Non-Participating Providers and Facilities — Reimbursement Policy

Policy CodePolicy 6-06092

Change TypeNo material change

Effective DateSep 6, 2024

Next Review DateN/A

Key ActionReimburse emergency services provided by nonparticipating providers/facilities up to the amount that would have been paid under Original Medicare, unless otherwise required by law or contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Original Medicarereimbursement amount benchmark

listed statesgeographic applicability

EMTALAfederal requirement adherence

subject to editsclaims processing

Emergency Services Coverage Rules

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Emergency services coverage rules

Covered when ALL of the following are met:

Anthem Medicare Advantage allows reimbursement for emergency services provided by nonparticipating professional providers and facilities unless prohibited by provider, state, federal, or CMS contracts or requirements.

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, unless otherwise required by federal regulation and/or contract.

Claims for emergency services are subject to Eligible Billed Charges, Code and Clinical Editing Guidelines, and Claims Requiring Additional Documentation policies; additional medical record documentation may be required to identify and determine appropriate reimbursement.

Anthem Medicare Advantage adheres to EMTALA and will not limit consideration of reimbursement based on lists of diagnoses or symptoms.

Billing Codes and Standards

Billing codesmixed

No codes listed

Code standards (CPT/HCPCS/revenue codes and documentation)

Coding systems requiredUse Current Procedure Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or revenue codes on all claim submissions.

Medical record supportAll billed codes must be fully supported in the medical record and/or office notes.

Billing compliance consequenceIf coding/billing guidelines or reimbursement policies are not followed, Anthem Medicare Advantage may recover/recoup payment, reject/deny the claim, or adjust reimbursement.

Applicability to provider typesUnless otherwise noted, reimbursement policies apply to both participating and non‑participating professional providers and facilities.

Use for accurate submissionThese policies serve as a guide to assist in accurate claims submissions and to outline the basis for reimbursement when Anthem Medicare Advantage covers the service.

Reimbursement Basis and Documentation Expectations

Billing Rule

Reimbursement basis for emergency services

Anthem Medicare Advantage allows reimbursement for emergency services provided by nonparticipating professional providers and facilities unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise; 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.

Documentation Required

Documentation and claim submission expectations

Claims for emergency services must follow billing and documentation guidelines; failure to use industry-standard compliant codes or to support billed services in the medical record may result in recovery/recoupment, claim rejection or denial, or adjusted reimbursement. Additional medical record documentation may be requested to determine appropriate reimbursement.

Use CPT, HCPCS, and/or revenue codes and ensure claims are fully supported in the medical record or office notes (chunk 1).
Anthem may recover/recoup payment, reject/deny, or adjust reimbursement if coding/billing guidelines or reimbursement policies are not followed (chunk 1).
Additional documentation may be required to clearly identify and determine appropriate reimbursement of emergency services (chunk 2).
Claims are subject to Eligible Billed Charges, Code and Clinical Editing Guidelines, and Claims Requiring Additional Documentation policies (chunk 2).

Regulatory and Contractual Governance

Emergency services — EMTALA and related contract requirements

EMTALA adherenceAnthem Medicare Advantage adheres to the requirements of the Emergency Medical Treatment and Labor Act (EMTALA).

Reimbursement stanceReimbursement is allowed for emergency services provided by non‑participating providers and facilities unless provider, state, federal, or CMS contracts/requirements indicate otherwise.

No diagnosis/symptom list limitationAnthem will not limit consideration of reimbursement for emergency services based on lists of diagnoses or symptoms.

Documentation may be requiredAdditional medical record documentation may be required to clearly identify and determine appropriate reimbursement for emergency services.

Subject to other policiesClaims for emergency services are subject to Anthem Medicare Advantage Eligible Billed Charges, Code and Clinical Editing Guidelines, and Claims Requiring Additional Documentation policies.