Critical Care in Emergency Department when Patient is Discharged to Home (Facility)
Defines how Premera recognizes and reimburses critical care services billed on an outpatient facility claim when the patient is discharged to home during the same encounter; applies to Premera and affiliated plans.
Clarified the first paragraph content in the policy section.
Removed the 'may be reviewed' statement from the third paragraph.
Removed the example codes from the fourth paragraph and removed other non-critical care example codes from the coding section.
Removed the effective date statement 'Effective with claim dates of service on and after October 30, 2024.'
Coverage Criteria
inv-01: Denial criteria for critical care in ED discharged to home
Critical care billed on an outpatient facility claim for ED encounters with discharge to home is not reimbursable under these conditions:
ALL of the following
- CPT codes 99291 and/or +99292 billed
Primary critical care and add-on critical care codes
- Revenue Code 450 present indicating an emergency room visit
- Discharge Status code 01 (discharged to home or self-care)
- Admission and discharge dates are the same OR discharge date is one day after admit date (indicating same-day or next-day discharge/spanning midnight)
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.