CurrentUnitedHealthcarePolicy 2025R6003A

Emergency department UB04 facility E/M level reimbursement

Defines how UnitedHealthcare reimburses facility UB04 claims for emergency department Evaluation and Management (E/M) Level 4 and Level 5 services for UnitedHealthcare Commercial and Individual Exchange plans, and describes use of an automated EDC Analyzer that may adjust billed levels.

Policy Summary

PayerUnitedHealthcare

PolicyEmergency department UB04 facility E/M level reimbursement

Policy CodePolicy 2025R6003A

Change TypeNon‑material revisions and template updates

Effective Date

Next Review DateSep 1, 2025

Key ActionFacility may resubmit a corrected claim with additional diagnosis or procedure codes and follow standard reconsideration and appeals processes.

SourceLink

POLICY UPDATE CHANGES

Policy Verbiage Section: EDC Analyzer Link updated; Q&A Section: Q&A 3 Updated.

Transferred content to shared policy template and updated Application section to indicate applicability to both UnitedHealthcare Commercial and Individual Exchange benefit plans.

Policy implemented by UnitedHealthcare Employer & Individual on 7/1/2017 and published 4/1/2017 (historical entries retained).

2E/M facility levels addressed

3EDC Analyzer factors

6Exclusion bullets

2Product lines named

Policy Summary

PayerUnitedHealthcare

PolicyEmergency department UB04 facility E/M level reimbursement

Policy CodePolicy 2025R6003A

Change TypeNon‑material revisions and template updates

Effective Date

Next Review DateSep 1, 2025

Key ActionFacility may resubmit a corrected claim with additional diagnosis or procedure codes and follow standard reconsideration and appeals processes.

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.

Reimbursement and exclusion criteria

UnitedHealthcare will reimburse ED facility E/M codes but may adjust or deny billed Level 4 or Level 5 codes based on the Optum Emergency Department Claim (EDC) Analyzer. The following criteria describe when reimbursement is allowed and which claims are excluded from EDC Analyzer adjustment.

Facility UB04 claims should be complete and include all diagnostic services and diagnosis codes relevant to the emergency department visit and be billed at the appropriate E/M level.

UnitedHealthcare will utilize the Optum Emergency Department Claim (EDC) Analyzer to determine the emergency department E/M level to be reimbursed for certain facility claims. The EDC Analyzer calculates a ‘Calculated Visit Level’ using three factors: presenting problems (ICD-10 reason for visit), diagnostic services performed (diagnostic CPT codes on the claim), and patient complexity/co-morbidity (ICD-10 principal, secondary, and external cause of injury codes).

Facilities may experience adjustments to submitted Level 4 or Level 5 E/M codes to a lower E/M code or may receive a denial for the submitted code level. For facilities experiencing adjustments, UnitedHealthcare may estimate reimbursement for the adjusted code based on historical claims experience; facilities may resubmit an adjusted claim which will be adjudicated based on the new charges and in accordance with this policy.

Facilities may resubmit corrected claims with additional diagnosis or procedure codes if originally omitted; follow standard reconsideration and appeals processes.

Claims excluded from EDC Analyzer adjustment

The patient is admitted to inpatient, has an outpatient surgery during the course of the same ED visit, or is discharged/transferred to other types of health care institutions.
Critical care patients billed with codes 99291 or 99292.
The patient is less than 2 years old.
Claims with certain diagnoses that when treated in the ED most often necessitate greater than average resource usage (for example, conditions requiring significant nursing time).
Patients who have expired in the emergency department.
Claims from facilities billing Level 4 and Level 5 E/M codes that do not deviate from the EDC Analyzer (i.e., billed level matches the EDC Analyzer calculated level).

ED Facility E/M Codes and Calculation Details

ED facility E/M and related codesmixed

99284	ED E/M Level 4 (facility)
99285	ED E/M Level 5 (facility)
G0383	HCPCS ED Level 4 facility
G0384	HCPCS ED Level 5 facility
99291	Critical care, evaluation and management of the critically ill or critically injured patient
99292	Critical care, each additional 30 minutes

EDC Analyzer calculated visit level — algorithm inputs

Algorithm inputsPresenting problems (ICD-10 reason for visit [RFV]), diagnostic services performed (diagnostic CPT codes on the claim such as lab, X‑ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound), and patient complexity/co‑morbidity (ICD‑10 principal, secondary, and external cause of injury diagnosis codes)

Calculated Visit LevelEDC Analyzer produces a Calculated Visit Level for the emergency department E/M services rendered using the three inputs above

Impact on billed codesFacilities may experience adjustments to billed Level 4 or Level 5 E/M codes to a lower level or receive denials when EDC Analyzer calculation differs from the submitted code

Resubmission after adjustmentFor facilities with adjustments, UnitedHealthcare may estimate reimbursement for the adjusted code; the facility may resubmit an adjusted claim which will be adjudicated based on the new charges

Corrected Claims, Appeals, and Provider Next Steps

Documentation Required

Resubmit corrected claim or pursue reconsideration/appeal

If the facility did not include all relevant and applicable diagnosis or procedure codes on the original claim, the facility may resubmit a corrected claim including those codes; alternatively, the facility may follow UnitedHealthcare's standard reconsideration and appeals processes for administrative claims determinations as described in the administrative guide.

Resubmit a corrected claim with appropriate diagnosis code(s) or procedure code(s) that may support the originally billed E/M level.
If you disagree with the reimbursement, follow UnitedHealthcare's standard reconsideration and appeals processes for administrative claims determinations as outlined in the administrative guide.

Definitions and Key Terms

Optum Emergency Department Claim (EDC) Analyzer

Tool name and purposeOptum Emergency Department Claim (EDC) Analyzer — an automated tool UnitedHealthcare utilizes to determine the emergency department E/M level to be reimbursed for certain facility UB04 claims

Role in reimbursementEDC Analyzer applies an algorithm to claim data to calculate a visit level; UnitedHealthcare may adjust or deny billed Level 4/5 facility E/M codes based on the Analyzer's result

Basis for useTool use is grounded in CMS coding principles and CPT/HCPCS code descriptions referenced by the policy

E/M Level 4 / Level 5

DefinitionFacility E/M Level 4 (CPT 99284 / HCPCS G0383) and Level 5 (CPT 99285 / HCPCS G0384) are emergency department evaluation and management codes used to bill facilities for ED visits based on intensity of hospital resources

Coding guidancePolicy follows CMS coding principles and the CPT/HCPCS code descriptors to determine appropriate and differential facility billing for ED visits

Related codesOther related facility codes referenced include critical care codes CPT 99291 and 99292; policy lists Level 4 and Level 5 specifically

OpenPayer

Emergency department UB04 facility E/M level reimbursement

Reimbursement and Exclusion Criteria

ED Facility E/M Codes and Calculation Details

Corrected Claims, Appeals, and Provider Next Steps

Definitions and Key Terms