CurrentUnitedHealthcarePolicy N/A

Emergency Room Reimbursement for Nebraska Medicaid

Defines UnitedHealthcare Community Plan Nebraska Medicaid reimbursement rules for emergency room services billed on UB-04 (or electronic equivalent) and which facility types and situations are affected.

Policy Summary

PayerUnitedHealthcare

PolicyEmergency Room Reimbursement for Nebraska Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFacility should review emergency room services and determine whether services provided constitute an Emergency Medical Condition and bill accordingly.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%ER room fee reduction for nonemergent visits

99281-99285ER evaluation CPT range

1st or 2ndDiagnosis position required to deem emergent

100%Other services paid when nonemergent

CAH 100%CAH payment rule

Emergency Room Payment Conditions

Non-emergent visit payment rule

When a visit is determined nonemergent:

Reduce ER room fee (revenue code 450 with CPT code from 99281-99285) by 50% of the otherwise allowed amount

Pay all other services at 100% of the provider fee schedule

If a diagnosis from the UnitedHealthcare Community Plan Nebraska ER ICD-10 Diagnosis List appears in the first or second diagnosis position on the claim, the claim will be considered emergent (and not subject to the reduction)

Critical Access Hospitals (CAH) are excluded from the non-emergent reduction and will be paid at 100% regardless of emergent or non-emergent diagnosis

Relevant Codes and Diagnosis Rules

Policy Summary

PayerUnitedHealthcare

PolicyEmergency Room Reimbursement for Nebraska Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFacility should review emergency room services and determine whether services provided constitute an Emergency Medical Condition and bill accordingly.

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.

ER room/ED evaluation codesCPT

99281-99285

Emergency department evaluation and management CPT code range used to identify ER room fee

ER room/ED evaluation codesRevenue

450	Revenue code identifying the emergency room room fee

Nebraska emergent diagnosis listICD-10

ICD-10

Diagnosis list (Nebraska ER ICD-10 Diagnosis List) — one of these must be in first or second position to deem emergent

Diagnosis position requirement — ICD-10 diagnosis must be in first or second diagnosis position to consider visit emergent

RequirementAn ICD-10 diagnosis from the Nebraska ER ICD-10 Diagnosis List must appear in the first or second diagnosis position on the claim to be considered emergent.

Effect when metIf a listed diagnosis is in first or second position, the claim will be considered emergent and full payment rules may apply.

Effect when not metIf no listed diagnosis appears in the first or second position, the claim will be subject to the non-emergent payment reduction for the ER room fee.

Relevant code listUnitedHealthcare Community Plan Nebraska ER ICD-10 Diagnosis List (attached to policy).

Billing noteThis diagnosis-position rule applies when determining whether the visit is considered emergent for payment; other criteria (e.g., EMC definition, inpatient admission, physician referral) are also considered.

Key Definitions

Emergency Medical Condition — definition used in policy

Definition (summary)A medical or behavioral condition with sudden onset and symptoms of sufficient severity that a prudent layperson could reasonably expect absence of immediate medical attention to result in serious jeopardy to health, serious impairment of bodily functions or organs, or serious disfigurement.

Examples of severityIncludes symptoms such as severe pain and situations that could place the health of the person (or pregnant woman and unborn child) in serious jeopardy.

Behavioral healthBehavioral conditions that could place the health of the person or others in serious jeopardy are included.

Policy useUsed as one of the criteria for approving full payment for emergency room services when the patient is evaluated or treated for an Emergency Medical Condition.

Critical Access Hospital (CAH) — definition and CAH payment exception

DefinitionA hospital licensed as a Critical Access Hospital by the Department of Health and Human Services under 175 NAC 9 and certified for participation by Medicare as a Critical Access Hospital.

Payment exceptionCritical Access Hospitals are excluded from the non-emergent reduction; claims received by a CAH will be paid at 100% of the fee schedule or provider contract regardless of emergent or non-emergent diagnosis.

ScopeApplies to claims billed by hospitals that meet state licensing and Medicare certification requirements for CAH status.

OpenPayer

Emergency Room Reimbursement for Nebraska Medicaid

Emergency Room Payment Conditions

Relevant Codes and Diagnosis Rules

Facility Review and Billing Instructions

Key Definitions