CurrentMolina HealthcarePolicy N/A

Emergency Department Facility E/M Reimbursement Policy

Governs Molina Healthcare's reimbursement approach for facility-level emergency department E/M codes (notably Level 4 and 5) and how claims may be adjusted or denied; affects facility providers submitting ED facility claims to Molina.

Policy Summary

PayerMolina Healthcare

PolicyEmergency Department Facility E/M Reimbursement Policy

Policy CodePolicy N/A

Change TypeAdministrative and template updatesinitial creation

Effective DateN/A

Next Review DateN/A

Key ActionFacilities may submit a revised claim if payment was estimated after an Optum EDC Analyzer adjustment.

SourceLink

POLICY UPDATE CHANGES

New policy created on 04/26/2024.

Template and formatting updated on 12/16/2024.

Template links updated on 08/06/2025.

Font, page number and PI number updated on 08/21/2025.

Level 4 & 5ED facility E/M codes specifically addressed

Optum EDC AnalyzerTool used

Inpatient, surgery, <2 yrs, critical care, deathExclusions that prevent changes

2024-04-26Policy creation

Policy Summary

PayerMolina Healthcare

PolicyEmergency Department Facility E/M Reimbursement Policy

Policy CodePolicy N/A

Change TypeAdministrative and template updatesinitial creation

Effective DateN/A

Next Review DateN/A

Key ActionFacilities may submit a revised claim if payment was estimated after an Optum EDC Analyzer adjustment.

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.

Coverage and Adjudication Criteria for ED Facility E/M

Molina will adjudicate facility ED E/M claims using the Optum EDC Analyzer and may adjust, reject, or require revised claims; certain situations are excluded from adjustment.

ED facility submits Level 4 or Level 5 E/M (99284/G0383 or 99285/G0384) claim to Molina Healthcare

Molina may use the Optum Emergency Department Claim (EDC) Analyzer to determine the payable ED E/M level

Payment level determined by the EDC Analyzer may be lower than the facility-submitted level and may result in adjustment or rejection of the submitted code.

When EDC Analyzer changes the payable code, Molina may estimate payment based on past claims experience and allow the facility to submit a revised claim

Revised claims will be processed based on the new charges in accordance with policy.

Exclusions — facility claims that are not subject to EDC Analyzer change or rejection include any of the following

Patient admitted to inpatient status during the ED visit
Patient has outpatient surgery during the same ED visit
Patient discharged or transferred to another healthcare facility
Critical care services billed (99291, 99292)
Patient under 2 years of age
Diagnoses that typically require above-average ED resources (e.g., conditions that require substantial nursing time)
Patient died in the emergency department
Submitted level matches the EDC Analyzer determination (no difference)

Molina reserves the right to deny, review, audit, and recover payments for any claim subject to medical necessity review

Rights exercised per this policy and payer/provider contract.

ED Facility E/M and Related Codes

ED Facility E/M and Critical Care CodesCPT

99284	ED Level 4 E/M (facility)
G0383	Hospital outpatient clinic visits - ED Level 4 equivalent
99285	ED Level 5 E/M (facility)
G0384	Hospital outpatient clinic visits - ED Level 5 equivalent
99291	Critical care, evaluation and management of the critically ill or critically injured — first 30–74 minutes
99292	Critical care, each additional 30 minutes

EDC Analyzer Adjustment

What the EDC Analyzer can doFacility-submitted Level 4 or 5 ED E/M (99284/G0383 or 99285/G0384) may be reduced to a lower E/M level or rejected based on the Optum Emergency Department Claim (EDC) Analyzer determination.

How reimbursement level is determinedOptum EDC Analyzer evaluates the submitted facility ED E/M claim and determines the payable E/M level; Molina will pay the level the tool identifies.

Estimated payments and revised claimsFor facilities that receive a changed Level 4/5 determination, Molina may estimate payment for the changed code based on past claims experience; the facility may submit a revised claim which Molina will process per policy.

Potential outcomes for submitted claimsSubmitted Level 4/5 may be (1) reduced to a lower level, (2) rejected for the submitted level, or (3) left unchanged if analyzer concurs.

Provider Actions, Claims Adjustment, Denials and Recovery

Billing Rule

EDC Analyzer-based Adjustment and Revised Claims

Molina Healthcare uses the Optum Emergency Department Claim (EDC) Analyzer to determine the ED E/M level payable for certain facility claims. Facilities may receive an adjusted payment level or a rejection when the EDC Analyzer determines a lower E/M code than submitted. If Molina estimates payment for a changed level 4 or 5 E/M code based on past claims experience, the facility may submit a revised claim; Molina will process the revised claim based on the new charges in accordance with this policy.

Facilities may receive an adjusted payment level or rejection when the EDC Analyzer determines a lower E/M code.
If Molina estimates payment for a changed code, submit a revised claim with updated charges for processing.

Denial Risk

Denial, Review, Audit and Recovery Rights

Molina reserves the right to deny, review, audit, and recover claims if medical necessity, coding, or documentation do not support the billed ED services or E/M level. Facility claims should be complete, include all diagnostic services and diagnosis codes related to the ED visit, and be billed at the appropriate E/M level. Some claims may be excluded from EDC Analyzer changes or rejections (for example: admission to inpatient or outpatient surgery during the same ED visit, critical care codes 99291/99292, patients under 2 years old, patients who died in the ED, claims with diagnoses that typically require above-average resources, or claims where billed levels agree with the EDC Analyzer). See the Optum Emergency Department Claim Analyzer guide for details.

Molina may deny, review, audit, and recoup payments when documentation or coding do not support billed services.
Ensure ED claims include all related diagnostic services and diagnosis codes and are billed at the correct E/M level.
Examples not typically subject to EDC Analyzer adjustment: inpatient admission/outpatient surgery during same ED visit; critical care (99291, 99292); patients <2 years old; patients who died in the ED; diagnoses that require high resource use; claims where billed E/M level matches the EDC Analyzer.

OpenPayer

Emergency Department Facility E/M Reimbursement Policy

Coverage and Adjudication Criteria

ED Facility E/M and Related Codes

Provider Actions, Claims Adjustment, Denials and Recovery

Definitions and Acronyms