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Effective February 1, 2026: Revised Payment Policy: Leveling of Care: Emergency Department Evaluation and Management Over-coding for Professional Services

Date: 10/31/25

Superior HealthPlan presents a new payment policy that replaces the existing policy for Emergency Department (ED) Evaluation and Management (E&M) Leveling of Care for Professional Services (CC.PP.053).  The new Leveling of Care: Emergency Department Evaluation and Management Over-coding for Professional Services policy provides the health plan’s billing and reimbursement requirements for ED based E&M procedure codes. As a result, the following policy has been created, and is posted on Superior’s Clinical, Payment and Pharmacy Policies webpage for review, prior to its implementation.

Policy

Effective Date

Applicable Products

New Policy Overview or Updated Policy Revisions

Leveling of Care: Emergency Department Evaluation and Management Over-coding for Professional Services

(CC.PP.076)

February 1, 2026

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP), Health Insurance Marketplace (Ambetter from Superior HealthPlan)

There are three key components providers must consider when selecting the appropriate level of E&M services provided, history, examination and medical decision making. Providers should consider the extent of the pertinent history obtained from the patient, the extent of the pertinent examination performed, and the complexity of medical decision-making. When selecting the appropriate level of E&M service, key components must meet or exceed the stated requirements to qualify for a particular level of E&M service (i.e., office, new patient, inpatient hospital care, office consultations, etc.).

When a provider submits an E&M service that exceeds the maximum level of E&M service based on the diagnosis and other claim documentation elements, the E&M code is reduced to reflect the maximum level of E&M service.

To review all clinical payment or payment policies, please visit Superior’s Clinical, Payment and Pharmacy Polices webpage.

For questions or additional information, please contact Superior Provider Services at: