Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Criteria for Reimbursement of Emergency Room Services

Policy #:

MA00.044b

Policy

Services that are performed in the emergency room (ER)/emergency department (ED) setting are reimbursed to participating professional providers and/or to the participating facility in which the services are provided. The Company applies the definition of emergency and diagnostic criteria to determine the appropriate level of reimbursement for these services.

In accordance with the facility and/or professional provider contracts, the following reimbursement methodologies may be applied to facility claims and claims submitted by professional providers who specialize in emergency medicine:

Eligible emergent services may be reimbursed at an emergency level.
Eligible services that are not considered emergent may be reimbursed at a triage level (i.e., a reduced rate).

For all other Company products, medically necessary ER/ED services are covered and eligible for reimbursement consideration as outlined in the applicable participating professional provider contract or participating facility contract.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This policy is consistent with Medicare's coverage determination for emergency room services. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, emergency room service is covered under the medical benefits of the Company's Medicare Advantage products.

Description

EMERGENCY LEVEL

Reimbursement eligibility for services rendered in an emergency room (ER)/emergency department (ED) setting to participating professional providers and/or to participating facilities is based on diagnostic criteria, the definition of emergency, and all applicable facility provider and/or professional provider contract terms.

Emergency is defined as the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any one of the following:

The health of the individual being placed in serious jeopardy
The health of a pregnant woman or her unborn child being placed in serious jeopardy
Serious impairment to the individual's bodily functions
Serious dysfunction of any of the individual's bodily organs or parts

Medical emergency situations include, but are not limited to:

Heart attacks, strokes, poisoning, loss of consciousness or respiration, and convulsions
Accidents such as, but not limited to, falls, severe cuts, broken bones, and other traumatic bodily injuries

TRIAGE LEVEL

When the individual's condition does not meet diagnostic criteria or the definition of emergency, the participating facility and/or participating professional provider, in accordance with the applicable provider contract, may receive a reduced level of reimbursement. This reduced level of reimbursement is referred to as a triage rate or triage level of reimbursement.

References

Centers for Medicare & Medicaid Services (CMS). Emergency Medical Treatment and Labor Act Technical Advisory Group (EMTALA TAG).[CMS Web site]. 03/26/2012. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA/. Accessed January 28, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections: 20.2 – Definitions of Emergency and Urgently Needed Services. [CMS Web site]. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf. Accessed January 28, 2020..

Commonwealth of Pennsylvania. Title 28: Health and Safety. Part I: General Health. §9.602: Definitions, emergency service. [The Pennsylvania Code Web site]. 06/09/01. Available at: http://www.pacode.com/secure/data/028/chapter9/s9.602.html. Accessed January 28, 2020..

Commonwealth of Pennsylvania. Title 28: Health and Safety. Part VII: Emergency Medical Services. §1001.2: Definitions, emergency medical services (EMS). [The Pennsylvania Code Web site]. 02/07/04. Available at: http://www.phila.gov/regionalems/PDF/RULESANDREGULATIONS.pdf. Accessed January 28, 2020.

Company Provider Manuals

Evidence of Coverage

New Jersey Department of Banking and Insurance. Health Insurance Programs: Individual Health Coverage Programs. Small Employer Benefits Programs. [New Jersey Department of Banking and Insurance Web site]. Available at: http://www.state.nj.us/dobi/reform.htm. Accessed January 28, 2020.

New Jersey Legislature. Assembly Health Committee Statement To Assembly, Bill No. 2829. [New Jersey Legislature Web site]. 02/23/2015. Available at: http://www.njleg.state.nj.us/2014/Bills/A3000/2829_S3.PDF. Accessed January 28, 2020.

Coding

CPT Procedure Code Number(s)

99281, 99282, 99283, 99284, 99285, 99291, 99292

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

Emergency Room - General 

Emergency Room - EMTALA Emergency Medical Screening Services

Emergency Room - ER Beyond EMTALA

Emergency Room - Urgent Care

Emergency Room - Other Emergency Room 

Trauma Response - Level I

Trauma Response - Level II

Trauma Response - Level III

Trauma Response - Level IV

Trauma Response - Other Trauma Response

Professional Fees - Emergency Room

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

3/23/2020

Version Issued Date: