CurrentIndiana Department of InsurancePolicy PROMOD00025

Emergency Services

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Coverage, screening, billing, prior authorization, and reimbursement requirements for emergency services provided to Indiana Health Coverage Programs members under fee-for-service, including emergency department screenings, nonemergency emergency-department services, and Package E and Package B emergency-only coverage.

Policy Summary

PayerIndiana Department of Insurance

PolicyEmergency Services

Policy CodePolicy PROMOD00025

Change TypeClarity edit and autopay-list note

Effective DateJanuary 1, 2024

Next Review DateN/A

Key ActionReport an emergency inpatient admission to the prior authorization contractor within 48 hours, excluding weekends and legal holidays.

SourceLink

POLICY UPDATE CHANGES

Version 7.0 edited policy text for clarity.

Version 7.0 added a note concerning emergency department autopay lists.

No PAPrior authorization requirement for emergency services

48 hoursEmergency inpatient admission reporting window

4 daysMaximum limited-supply prescription period for Package E and Package B claims

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CurrentIndiana Department of InsurancePolicy PROMOD00025

Emergency Services

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Policy Summary

PayerIndiana Department of Insurance

PolicyEmergency Services

Policy CodePolicy PROMOD00025

Change TypeClarity edit and autopay-list note

Effective DateJanuary 1, 2024

Next Review DateN/A

Key ActionReport an emergency inpatient admission to the prior authorization contractor within 48 hours, excluding weekends and legal holidays.

SourceLink

POLICY UPDATE CHANGES

Version 7.0 edited policy text for clarity.

Version 7.0 added a note concerning emergency department autopay lists.

No PAPrior authorization requirement for emergency services

48 hoursEmergency inpatient admission reporting window

4 daysMaximum limited-supply prescription period for Package E and Package B claims

Screening-only emergency department revenue code

99281-99285Emergency department screening CPT codes

EOB 4180Explanation of benefits code for nonpayable services with revenue code 451

Emergency Services Coverage Criteria

Emergency medical condition

An emergency service is covered when the emergency medical condition standard is met.

Serious consequence: Absence of immediate medical attention could reasonably be expected to result in serious jeopardy to health, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part.At least one consequence
For a pregnant woman, health of the woman or unborn child is included.

Emergency department screening and treatment

Emergency department services are covered based on the screening determination.

Emergency department screening outcome: The screening physician determines that the member has an emergency condition, in which case medically necessary emergency services may be billed; or the screening is necessary to determine whether an emergency condition exists, in which case the screening itself is reimbursable.Screening result determines billing pathway

If the screening does not establish an emergency, hospitals bill only the screening service.

Package E and Package B members

Package E and Package B emergency-only services are covered when the service meets the applicable emergency or pregnancy-related criteria.

Package E emergency coverage: The member has qualifying Package E coverage and the service meets the emergency criteria in the Introduction.Emergency criteria must be met

Labor and delivery for a pregnant woman with Package E are considered emergency medical conditions.

Package B coverage: The member has Package B coverage and the service is an emergency service, pregnancy-related service, or postpartum service within the benefits described for Package B.Emergency, prenatal, or postpartum service

Package B provides Package E benefits plus prenatal and postpartum services.

Hospitals are not reimbursed for nonemergency services provided in an emergency-room setting. When the screening does not establish an emergency medical condition, reimbursement is limited to the necessary screening service.

When the screening does not indicate an emergency visit, the hospital must bill only revenue code 451 for the emergency medical screening. Emergency-room treatment and ancillary services billed with revenue code 451 are not reimbursed; all ancillary charges submitted with that code are denied under EOB 4180.

Related emergency-room services, including facility, laboratory, and X-ray charges, must include a principal diagnosis code supporting the emergency nature of the service. Claims may be suspended for prudent-layperson review and denied when the review determines that the emergency standard was not met.

Coding and Billing Requirements

Emergency department revenue codesRevenue

451	Emergency Medical Treatment and Labor Act (EMTALA) Emergency Medical Screening Services
450	Emergency Room - General

Emergency department screening CPT codesCPT

99281-99285

Appropriate level of emergency department screening examination performed

Emergency claim indicatorsModifier

EMG	Emergency indicator field for professional claims

Inpatient admission type codesRevenue

1	Admission type indicating an emergency admission
5	Admission type indicating a trauma admission

Explanation of benefits codemixedNot Covered

4180	When revenue code 451 is billed on an outpatient or outpatient crossover claim, all other services billed are not payable

Emergency inpatient admission reporting

Reporting deadlineReport the emergency inpatient admission to the prior authorization contractor within 48 hours after admission.

Excluded daysThe 48-hour reporting window does not include Saturdays, Sundays, or legal holidays.

Prior authorization contextEmergency services do not require prior authorization; an inpatient stay resulting from an emergency admission generally does, subject to stated exemptions.

Package E and Package B pharmacy claims

Maximum prescription periodA limited-supply prescription may cover a maximum of four days.

Provider Responsibilities and Action Items

Prior Authorization

Report Emergency Admissions for Inpatient Reimbursement

Emergency services do not require prior authorization and are self-referral services, including for members with an assigned primary medical provider through managed care or the Right Choices Program. However, an inpatient stay resulting from an emergency admission requires prior authorization, except for qualifying burn-care admissions and services otherwise exempt from inpatient authorization requirements; report the emergency admission to the PA contractor within 48 hours after admission, excluding Saturdays, Sundays, and legal holidays.

Emergency services are excluded from fee-for-service copayment requirements.
Burn-care stays with admission type 1 (emergency) or 5 (trauma) are exempt from the resulting inpatient PA requirement.

Documentation Required

Submit Records for Prudent-Layperson Review

If the provider believes the situation meets the emergency medical condition definition but the applicable diagnosis code may not appear on the contractor’s Emergency Department Autopay List, submit medical records with the initial claim for prudent-layperson review.

Policy Background

Emergency services are unscheduled episodic services provided after the sudden onset of an emergency medical condition requiring immediate medical attention. Coverage is based on the prudent-layperson standard: whether the presenting acute symptoms, including severe pain, could reasonably be expected to cause serious jeopardy to health, serious impairment of bodily functions, or serious dysfunction of an organ or body part without immediate attention. The screening physician determines whether an emergency condition is present.

Key Definitions

Emergency medical condition

Acute symptomsThe condition must manifest acute symptoms of sufficient severity, including severe pain.

Expected consequencesA prudent layperson with average knowledge of health and medicine could reasonably expect that without immediate medical attention, the condition would place the individual's health in serious jeopardy, seriously impair bodily functions, or cause serious dysfunction of a bodily organ or part.

PregnancyFor a pregnant woman, serious jeopardy includes jeopardy to the health of the woman or her unborn child.

Prudent layperson standard

Assessment basisEmergency status is assessed from the acute symptoms presenting at the time of care, not solely from the final diagnosis.

Person applying the standard

Policy Summary

PayerIndiana Department of Insurance

PolicyEmergency Services

Policy CodePolicy PROMOD00025

Change TypeClarity edit and autopay-list note

Effective DateJanuary 1, 2024

Next Review DateN/A

Key ActionReport an emergency inpatient admission to the prior authorization contractor within 48 hours, excluding weekends and legal holidays.

SourceLink

On This Page

Eligible membersThe prescription requirement applies to Package E and Package B members.

Claim requirementsThe pharmacy claim must be associated with a covered emergency medical service, include the emergency indicator field, and be submitted on a paper pharmacy claim.

The review applies the prudent-layperson standard: whether a person with average health and medical knowledge could reasonably expect that without immediate attention the condition would place health in serious jeopardy, seriously impair bodily functions, or cause serious dysfunction of an organ or body part.

Documentation Required

Maintain Package E and Package B Supporting Documentation

For Package E and Package B members, maintain documentation supporting that the service meets the emergency-service definition and that the claim is appropriate. Claims must identify the applicable emergency, pregnancy, or postpartum service indicators.

Professional claims: mark the EMG field for each service detail.
Institutional outpatient claims: report an emergency diagnosis code in the principal position.
Institutional inpatient claims: report admission type code 1 for an emergency admission.
Dental claims: enter “Emergency” in the Predetermination/Preauthorization Number field on paper claims or mark the electronic emergency indicator; the procedure must be an IHCP-designated emergency dental service.
Package E covers qualifying emergency services only; for pregnant members, labor and delivery are emergency medical conditions. Package B provides the same benefits plus prenatal and postpartum services.

Billing Rule

Bill According to the Screening Determination

The screening physician determines whether the member has an emergency medical condition. Hospitals are reimbursed for screenings necessary to make that determination, and emergency department physicians are reimbursed for medically necessary emergency services.

When the screening confirms an emergency condition, bill the medically necessary emergency services under the appropriate revenue code, such as 450, with applicable procedure codes; do not bill revenue code 451 for the screening.
Physicians must bill professional services using CPT codes 99281–99285 for the appropriate emergency department screening level.
If the emergency department visit results in an inpatient stay, reimbursement is included in the inpatient DRG.

Denial Risk

Support the Emergency Diagnosis

Related emergency-room services, including facility charges, laboratory services, and X-rays, must include a principal diagnosis code supporting the emergency nature of the service. Without a supporting principal diagnosis, the IHCP may suspend the claim for prudent-layperson review and will deny it if the review finds that the standard was not met.

The requirement applies to related services provided in an emergency-room setting.

Denial Risk

Do Not Bill Ancillaries With Revenue Code 451

When the screening does not indicate an emergency medical condition, bill only the screening service with revenue code 451 (Emergency Medical Screening Services). Do not submit ancillary or other emergency-room treatment charges with revenue code 451.

All ancillary charges submitted with revenue code 451 will be denied.
EOB 4180 applies when revenue code 451 is billed on an outpatient or outpatient crossover claim and all other billed services are not payable.

Billing Rule

Limit Payment for Nonemergency Emergency-Room Treatment

The IHCP does not reimburse hospitals for nonemergency services rendered in an emergency-room setting. If the screening does not indicate an emergency medical condition, the hospital is reimbursed only for the screening billed with revenue code 451.

Physicians treating patients whose screenings do not indicate an emergency should use the applicable office-visit procedure code, not an emergency-room screening code, and report the emergency-department place of service; a site-of-service reduction may apply.
Members with Presumptive Eligibility–Adult coverage owe an $8 copayment for nonemergency emergency-department services; managed care copayments may also apply.

The standard asks what a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect.

Immediate-attention testThe question is whether the presenting symptoms could reasonably be expected to cause serious jeopardy to health, serious impairment to bodily functions, or serious dysfunction of an organ or body part without immediate medical attention.

Package E

Coverage typePackage E provides Emergency Services Only coverage for qualifying non-U.S. citizens.

Covered servicesBenefits are limited to services that meet the emergency criteria stated in the policy introduction.

Pregnancy-related exceptionFor pregnant women with Package E coverage, labor and delivery services are considered emergency medical conditions.

Package B

Coverage typePackage B is Emergency Services Only coverage with pregnancy coverage, also known as ESO Coverage with Pregnancy Coverage.

Emergency benefitsPackage B provides the same emergency-service benefits as Package E.

Pregnancy benefitsPackage B also covers prenatal and postpartum services.