Revised Implementation Date: New Payment Policy - Leveling of Care: Emergency Department Evaluation and Management Over-coding for Professional Services
Date: 04/15/26
Superior HealthPlan and Celtic Insurance Company present a revised payment policy that replaces the existing policy for Emergency Department (ED) Evaluation and Management (E&M) Leveling of Care for professional services. The new implementation date of the revised Leveling of Care: Emergency Department Evaluation and Management Over-coding for Professional Services (CC.PP.053) policy provides health plan’s billing and reimbursement requirements for ED based Evaluation and Management (E&M) procedure codes is May 1, 2026. The following policy 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) | May 1, 2026 | Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP), Health Insurance Marketplace (Ambetter from Superior HealthPlan and Ambetter Health Solutions) | 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 your local Provider Representative. To find their contact information please visit the Find My Provider Representative webpage.
Please note: This article is an update from the previously posted article: Effective February 1, 2026: Revised Payment Policy: Leveling of Care: Emergency Department Evaluation and Management Over-coding for Professional Services.