RETRACTED: E/M services accuracy initiative

Beginning August 1, 2025, we will be implementing a process to help make sure coding on claims aligns with national industry coding standards. This initiative is part of our ongoing effort to promote accurate claims processing and payment.

The review process

Claims will be selected from care providers who are identified as coding at a higher E/M level compared to their peers with similar risk‑adjusted members.

Prior to payment, we will review the selected E/M claims to determine whether the E/M code level submitted is higher than the E/M code level supported on the claim.

If the E/M code level submitted is higher than the E/M code level supported on the claim, we may:

• Not reimburse the claim and request resubmission of the claim with the appropriate E/M level.
• Pend the claim and request documentation supporting the E/M level billed.
• Adjust reimbursement to reflect the lower E/M level supported by the claim.

The maximum level of service for E/M codes will be based on the complexity of the medical decision‑making and reimbursed at the supported E/M code level and fee schedule rate.

This initiative will not impact every level four or five E/M claim. Care providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.

Care providers who believe a claim reimbursement decision should be reviewed should follow the claims payment dispute process outlined in the provider manual on the provider website.

If you have questions, please contact your group administrator or your network representative.