CurrentMolina HealthcarePolicy N/A

Member PCP as Attending Provider in an ER setting

Governs Molina Healthcare reimbursement guidance when a member's Primary Care Physician (PCP) is listed as the attending provider on an emergency room (ER) facility claim; affects providers and facilities billing Molina for ER services.

Policy Summary

PayerMolina Healthcare

PolicyMember PCP as Attending Provider in an ER setting

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure facility claims list the ER physician, nurse, or qualified personnel who provided emergency care and do not list the member's PCP as the provider who saw the member in the ER.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1PCP shouldn’t be listed

1Denial/recovery authority

1CMS/state references

Provider Listing Criteria for ER Facility Claims

ER facility claim provider listing criteria

Reimbursement and billing criteria when a PCP is listed as attending provider in an ER facility claim:

ER facility claims must list the ER physician, nurse, or other qualified personnel who evaluated and treated the patient; do not list the member's Primary Care Physician (PCP) as the provider who saw the member in the ER.

The facility claim must accurately reflect the provider who evaluated and treated the patient to avoid confusion, billing errors, and potential delays in insurance processing.

Consequences

Molina Healthcare may deny, review, audit, and recover claims if the PCP is incorrectly listed or if billing is inaccurate or not medically necessary.

Provider and facility billing must follow federal/state guidelines and member benefit plan terms; contractual or regulatory requirements supersede this policy where applicable.

Coding Guidance and Compliance

Coding guidance / disclaimermixed

Coding disclaimer: codes listed in policy are for reference only; providers must follow industry standard coding practices.

Coding compliance — expectations and consequences (inv-03)"

Coding expectationProviders and facilities are expected to utilize industry standard coding practices for all submissions.

Coding disclaimerCodes listed in this policy are for reference only; deleted or inactive codes may not be eligible for reimbursement and listing a code does not guarantee coverage.

Denial/recovery for improper billingWhen improper billing and coding is not followed, Molina has the right to reject/deny the claim and recover claim payment(s).

Standards adheredMolina adheres to Current Procedural Terminology (CPT®) and nationally accepted industry coding principles.

Policy revision rightMolina reserves the right to revise this policy as industry practices change.

Claims Review, Recovery Authority, and Billing Documentation

Denial Risk

Claims review and recovery authority / billing accuracy

Molina Healthcare retains the authority to deny, review, audit, and recover claims when the billing is inaccurate or the claim does not reflect the provider who actually delivered emergency care. Providers must ensure facility ER claims accurately identify the ER physician, nurse, or other qualified personnel who evaluated and treated the member. Listing a member's Primary Care Physician (PCP) as the attending provider on an ER facility claim is incorrect and may result in denial, audit, or recovery of payments.

Incorrectly listing the PCP on an ER facility claim may trigger claim denial, delays, or recovery actions.
Facility claims must reflect the actual ER provider who performed the medical screening, evaluation, and treatment.
Ensure documentation supports the named attending provider on the facility claim to avoid audit findings and recoupment.

Documentation Required

Billing documentation requirement

The facility claim must list the ER physician, nurse, or other qualified personnel who provided the emergency care. Do not list the member's PCP as the attending provider on ER facility claims. Accurate provider attribution prevents billing errors, processing delays, and potential payment recovery.

List the ER physician, nurse, or qualified personnel as the attending provider on facility ER claims.
Do not list the member's PCP as the provider who saw the member in the ER.
Maintain documentation showing which ER clinician evaluated and treated the patient to support the claim.

CMS and State Medicaid Applicability

CMS / State Medicaid applicability and exceptions (inv-06)"}]} PMID:NULL

Federal/state precedenceFederal and state guidelines, as applicable, and the member's benefit plans supersede the information in this policy.

Provider contract precedenceTo the extent of conflicts between this policy and the provider contract language, the provider contract language will prevail.

CMS referenceThis policy was developed using CMS guidance; the Centers for Medicare & Medicaid Services is the federal agency that administers Medicare and partners with states on Medicaid/CHIP.

State exceptionsIf there is a state exception, refer to the state exception table listed in the policy.

State Medicaid guidancePolicy development referenced State Medicaid Regulatory Guidance and State Contracts.