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Effective September 1, 2026: Revised Payment Policy- Leveling of Care: Emergency Department Evaluation and Management Over-coding for Facility Services
Act
by Sep 1, 2026
Effective date
Sep 1, 2026
Identified
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.
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What to do
by Sep 1, 2026 · 5 steps
01Billing 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.
02Providers must ensure complete documentation of all laboratory services, imaging, procedures, and treatments performed during ED visits.
03Update billing compliance audits to flag ED claims where the billed E/M level may not align with documented resource utilization.
04Educate ED providers and documentation staff that unsupported E/M levels will result in automatic downleveling and reduced reimbursement.
05Note: Claims with critical care codes (99291, 99292) may be excluded from this policy review.
Codes mentioned
9929199292
Original notice
Effective September 1, 2026: Revised Payment Policy- Leveling of Care: Emergency Department Evaluation and Management Over-coding for Facility Services
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