CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Emergency Services: Non-Participating Providers and Facilities

This policy governs reimbursement for emergency services provided by nonparticipating professional providers and facilities for Highmark BCBS members in specified product lines, including Medicaid MMC, HARP, and CHPlus. It outlines payment bases, adherence to federal/state requirements, and documentation and coding expectations.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyEmergency Services: Non-Participating Providers and Facilities

Policy CodePolicy N/A

Change TypeReview approved: no changes

Effective DateSep 6, 2024

Next Review DateN/A

Key ActionObtain appropriate authorization and document medical necessity per procedure and diagnosis; medical records may be requested to determine reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicaid FFS rateReimbursement basis for Medicaid product lines

Out-of-network rateReimbursement basis for non-Medicaid

EMTALA & DRAFederal laws referenced

MMC, HARP, CHPlusPrograms mentioned

Emergency Services Reimbursement Criteria

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Emergency services reimbursement criteria

Highmark BCBS allows reimbursement for emergency services provided by nonparticipating professional providers and facilities, subject to state/federal requirements and documentation expectations.

Reimbursement is allowed unless provider, state, federal, or CMS contracts and/or requirements state otherwise.

ALL of the following

For Medicaid product lines (MMC, HARP, CHPlus): reimbursement equals the amount that would have been reimbursed by New York State Fee-for-Service (FFS) Medicaid.
For all other product lines: reimbursement is the applicable out-of-network emergency rate for nonparticipating providers and facilities.

Highmark BCBS follows the Emergency Medical Treatment and Labor Act (EMTALA) and the Federal Medicaid Managed Care Regulations.

Highmark BCBS will act in accordance with the Deficit Reduction Act (DRA) of 2005 Section 6085; providers without established Medicaid managed care contract payment amounts must accept as payment in full no more than the amounts they could collect under State FFS Medicaid (subject to DRA provisions).

Highmark BCBS will maintain records of its payment methodology pursuant to DRA stipulations for New York's FFS Medicaid program.

Reimbursement will not be limited by lists of diagnoses or symptoms; however, additional medical record documentation may be required to clearly identify and determine appropriate reimbursement of emergency services.

ALL of the following

Claims for emergency services are subject to the Eligible Billed Charges policy.
Claims for emergency services are subject to the Code and Clinical Editing Guidelines.
Claims for emergency services are subject to the Claims Requiring Additional Documentation policy.

Authorization and Documentation Requirements

Documentation Required

Authorization, medical necessity, and supporting documentation required for reimbursement

Submit authorization and medical necessity documentation appropriate to the procedure and diagnosis; emergency services reimbursement requires that services meet authorization and medical necessity guidelines and be supported in the medical record or office notes. Highmark BCBS may request additional medical record documentation to clearly identify and determine appropriate reimbursement of emergency services.

Use industry-standard CPT, HCPCS, and/or revenue codes that are fully supported in the medical record or office notes.
Ensure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

General Reimbursement Policy Definitions

Definitions headingGeneral Reimbursement Policy Definitions

Related policy: Claims Requiring Additional DocumentationSee Claims Requiring Additional Documentation for documentation requirements and potential requests for additional medical records.

Related policy: Claims Submissions - Required Information for FacilitiesSee Claims Submissions - Required Information for Facilities for facility claim submission requirements.

Related policy: Claims Submissions - Required Information for Professional ProvidersSee Claims Submissions - Required Information for Professional Providers for professional provider claim submission requirements.

Related policy: Code and Clinical Editing GuidelinesSee Code and Clinical Editing Guidelines for coding and editing rules that apply to reimbursement determinations.

Related policy: Eligible Billed ChargesSee Eligible Billed Charges for rules on allowable billed amounts used in reimbursement calculations.

Related policy: Sanctioned and Opt-Out ProvidersSee Sanctioned and Opt-Out Providers for how sanctions or opt-out status affect reimbursement eligibility.