Skip to Main Content

Our vendor, Berkeley Research Group, experienced a privacy incident. To learn more, please read the notice.

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

Date: 07/15/26

Superior HealthPlan, Ambetter from Superior HealthPlan and Ambetter Health Solutions (ICHRA) presents a revised payment policy, which replaces current Leveling of Emergency Room Services - Facility (CC.PP.064) payment policy. The following revised policy,  Leveling of Care: Emergency Department Evaluation and Management Over-coding for Facility Services (CC.PP.80) is posted on the Superior’s Clinical, Payment and Pharmacy Policies webpage for review, prior to its implementation.

Policy

Effective Date

Applicable Products

Revised Policy Overview or Updated Policy Revisions

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

(CC.PP.80)

September 1, 2026

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP), Marketplace (Ambetter from Superior HealthPlan and Ambetter Health Solutions), Medicare D-SNP and Medicare AIP D-SNP (Wellcare By Allwell, and Wellcare By Superior HealthPlan)

This payment policy supports reviews of facility-reported ED E/M levels for consistency with resources reported on the claim, including laboratory services, imaging, procedures, treatments, and other billed services. When the billed level of service is not supported by the claim evidence, reimbursement will be adjusted to the appropriate ED E/M level, up to and including the minimum level of service, based on the resources documented on the claim.

CPT codes submitted on a claim that critical care patients  (99291, 99292) receiving services in the Emergency Department of a facility may exclude Facility claims from being subject to the Leveling of Care ED policy.

 

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

For any questions, please contact your Provider Representative. To access their contact information visit Find My Provider Representative.