Medicare AdvantageDocumentationHigh impact
Special Alert May 2026 - Optum Emergency Department Claim Analyzer
Providence Health Plan·Emergency Medicine·Coding
Effective date
Jul 1, 2026
We identified it
May 1, 2026
Summary
Effective July 1, 2026, Providence Health Plan will implement the Optum Emergency Department Claim (EDC) Analyzer to review facility ED claims for Commercial and Medicare members. The tool will automatically evaluate whether billed ED levels (CPT 99283, 99284, 99285) are supported by documented intensity, services, and complexity. Claims not supported by documentation may be adjusted to the appropriate level or denied, requiring providers to ensure accurate ED leveling and complete coding.
Action Required
By July 1, 2026: Billing team and ED providers must ensure all ED facility claims are billed with accurate ED levels (CPT 99283, 99284, 99285) that match the documented intensity of services, procedures, diagnoses, and patient complexity. Review internal ED leveling guidelines for alignment with national coding standards. Ensure complete and accurate diagnosis codes, procedure codes, and revenue codes are submitted on all UB04/8371 ED facility claims. Update staff training to emphasize that claims with unsupported ED levels will be denied or downleveled per the EDC Analyzer logic. Monitor claims submitted on or after 7/1/2026 for adjustment notices and be prepared to appeal with complete medical records and supporting documentation per existing dispute processes. Contact your Provider Relations representative with questions about impact to your specific contracts.