New Payment Policy: Leveling of Care: Office-Based Evaluation and Management Over-coding
Date: 04/15/26
Superior HealthPlan and Celtic Insurance Company present a new payment policy for office and other outpatient Leveling of Care: Office-based Evaluation and Management (E&M) Over-coding (CC.PP.066), with an implementation date of June 1, 2026. 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: Office-based Evaluation and Management Over-coding (CC.PP.066) | June 1, 2026 | 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) | The purpose of this policy is to ensure that the level of E&M service reported by the provider reflects the services performed. 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. The following services will be reviewed to validate correct coding:
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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 your local Provider Representative. To find their contact information please visit the Find My Provider Representative webpage