CommercialReimbursementHigh impact
Special Alert May 2026 - Optum Emergency Department Claim Analyzer
Providence Health Plan·OR · Emergency Medicine·Coding
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Effective July 1, 2026, Providence Health Plan will implement the Optum Emergency Department Claim (EDC) Analyzer to review facility ED claims billed with CPT codes 99283, 99284, or 99285. Claims will be assessed against documentation of intensity, services, and patient complexity; billed levels not supported by documentation may be adjusted or denied. Professional physician ED services are unaffected.
Action Required
By July 1, 2026: Billing team must implement the following: (1) Verify all ED facility claims submitted on UB04 or 8371 forms with CPT 99283, 99284, or 99285 will be subject to EDC Analyzer review. (2) Update internal ED leveling guidelines and staff training to align with national coding standards and EDC Analyzer evaluation criteria. (3) Ensure complete and accurate diagnosis codes, procedure codes, and revenue codes are submitted with all ED facility claims to support the billed level of service. (4) Establish a process to review claim denials or payment adjustments resulting from EDC Analyzer determinations and prepare documentation/appeals as needed using standard reconsideration processes. (5) Communicate to ED providers that billed ED levels must align with intensity of services rendered. Failure to submit accurate supporting documentation will result in claim payment adjustments or denials requiring correction to the appropriate level of service. Note: Professional physician ED E/M claims, wrap-network/out-of-network/case rate contracts, inpatient admissions, critical care (99291, 99292), and members under 2 years old are excluded.