DMAS specifications for ER physician non-emergent payment reduction policy

In accordance with the Commonwealth of Virginia’s 2020 Appropriation Act, HealthKeepers, Inc. will be implementing the following new reimbursement policy for emergency room payments, effective July 1, 2020. This policy, together with reimbursement specifications, will also be added to the Anthem HealthKeepers Plus provider manual.

 

The 2020 Appropriation Act (Chapter 1289) includes the following changes in emergency room facility and physician reimbursement.

 

Item 313.AAAAA The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance Services to allow the pending, reviewing and the reducing of fees for avoidable emergency room claims for codes 99282, 99283 and 99284, both physician and facility. The department shall utilize the avoidable emergency room diagnosis code list currently used for Managed Care Organization clinical efficiency rate adjustments. If the emergency room claim is identified as a preventable emergency room diagnosis, the department shall direct the Managed Care Organizations to default to the payment amount for code 99281, commensurate with the acuity of the visit. The department shall have the authority to implement this reimbursement change effective July 1, 2020, and prior to the completion of any regulatory process undertaken in order to effect such change.

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0268-20