Evaluation & Management Services
Defines Highmark Blue Shield NENY's requirements for selecting E/M service levels (based on medical decision making or time) and eligibility for reimbursement across commercial and Medicare Advantage markets listed, affecting providers billing E/M codes to the Plan.
As of January 1, 2023, all Evaluation and Management services are selected and scored based on medical decision-making (MDM) or time.
Emergency Department codes (99281-99285) use only MDM to determine level of care.
Plan will no longer require the 3 components or reference face-to-face time when reporting New Patient Services; selection is based on MDM or time.
Plan will no longer require 2 of 3 components or reference face-to-face time when reporting Established Patient Services; selection is based on MDM or time.
Time that counts toward time-based E/M includes exam/evaluation, prep, counseling, documentation, orders, care coordination; certain time and separately billed services are excluded.
When a test or image interpretation is billed separately, orders and interpretation of that data cannot be included when determining E/M level based on MDM.
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.