MedicaidReimbursementHigh impact
Effective September 1, 2026: Revised Payment Policy- Leveling of Care: Emergency Department Evaluation and Management Over-coding for Facility Services
Ambetter·TX · Emergency Medicine·Coding
Effective date
Sep 1, 2026
We identified it
Aug 26, 2026
Summary
Superior HealthPlan is replacing its emergency department leveling policy (CC.PP.064) with a new policy (CC.PP.80) effective September 1, 2026, that will conduct post-claim reviews of facility-reported ED E/M levels for consistency with documented resources (labs, imaging, procedures, treatments). Claims with E/M levels not supported by documented resources will be downleveled to the appropriate level, potentially reducing reimbursement. Critical care CPT codes (99291, 99292) may exclude facility claims from this review.
Action Required
By September 1, 2026: Billing team must implement claims review procedures to ensure ED facility claims are submitted with E/M levels fully supported by documented resources on the claim. Providers must ensure complete documentation of all laboratory services, imaging, procedures, and treatments performed during ED visits. Update billing compliance audits to flag ED claims where the billed E/M level may not align with documented resource utilization. Educate ED providers and documentation staff that unsupported E/M levels will result in automatic downleveling and reduced reimbursement. Note: Claims with critical care codes (99291, 99292) may be excluded from this policy review.