Material Adverse Change (MAC)

 

Effective September 1, 2021, Anthem classifies with an evaluation and management (E&M) code level the intensity/complexity of emergency department (ED) interventions a facility utilizes to furnish all services indicated on the claim. E&M services will be reimbursed based on this classification. Facilities must utilize appropriate HIPAA compliant codes for all services rendered during the ED encounter. If the E&M code level submitted is higher than the E&M code level supported on the claim, we reserve the right to perform one of the following:

  • Deny the claim and request resubmission at the appropriate level or request the provider submit documentation supporting the level billed
  • Adjust reimbursement to reflect the lower ED E&M classification
  • Recover and/or recoup monies previously paid on the claim in excess of the E&M code level supported


Please refer to the Emergency Department: Level of Evaluation and Management Services reimbursement policy for additional details at anthem.com/provider.


Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E&M service will be able to follow the dispute resolution process in accordance with the terms of their contract. Claims disputes require a statement providing the reason the intensity/complexity would require a different level of reimbursement and the medical records which should clearly document the facility interventions performed and referenced in that statement.


1155-0621-PN-NV



Featured In:
June 2021 Anthem Provider News - Nevada