Emergency department reimbursement policy
Anthem Blue Cross and Blue Shield (Anthem) is dedicated to delivering better care to our members, providing higher value to our customers, and helping to improve the health of our communities.
In 2013, Anthem implemented the Emergency Department (ED) Reimbursement Policy. The policy is set forth in the Facility Provider Manual, as applicable, and outlines the levels of emergency room services and states that “the highest level evaluation and management (E&M) code for which a claim clinically qualifies will be used to determine the level of reimbursement, as applicable for ED services.” Currently, Anthem is using a post-pay manual review process to determine the level of service by asking for and reviewing the medical records for the emergency room visit.
Anthem to engage a vendor to assess selected claims for E&M services beginning January 1
In an ongoing effort to ensure accurate claims processing and payment and to decrease the amount of medical records being requested for this policy, effective January 1, 2021, Anthem will begin to use a vendor to assess selected claims for evaluation and management services. An automated analytic solution will be used to better ensure that benefit payments are aligned with national industry coding standards. As outlined in the policy, Anthem will adjust the reimbursement to reflect the lower ED E&M classification for those claims that do not meet the higher level criteria.
As always, providers who feel that the level of reimbursement should be reconsidered can file an appeal in accordance with the terms of their contract. Claim appeals require a statement providing the reason the intensity/complexity would require a different level of reimbursement as well as the medical records which should clearly document the facility interventions performed and referenced in that statement.
If you have questions about the amendment process, please contact your Anthem Network Manager. View the Anthem contact list online at anthem.com.
October 2020 Anthem Provider News - Virginia