MedicaidReimbursementHigh impact
Emergency Department Facility E/M Leveling Update (PDF)
Ambetter·MO · Emergency Medicine·Provider Bulletin
Effective date
Sep 15, 2026
We identified it
Aug 26, 2026
Summary
Home State Health is transitioning ED facility E/M leveling from Optum (Policy CC.PP.064) to Cotiviti (Policy CC.PP.80), effective September 15, 2026. The new vendor will conduct pre-payment clinical review with a Level 3 payment floor, ensuring claims are not reduced below CPT 99283/G0382. This enhances transparency and CMS alignment but does not introduce new denials or remove appeal rights.
Action Required
By September 15, 2026: Billing team must transition ED facility E/M claim processing from the Optum EDC Analyzer to the Cotiviti leveling system. Verify that all hospital-based and free-standing ED claims (CPT 99281-99285; HCPCS G0380-G0384) route through the new Cotiviti pre-payment review process in the billing system. Confirm that claims cannot be adjusted below Level 3 (CPT 99283/G0382) in system settings. Brief ED coding and billing staff that the new vendor uses resource-consumption methodology (services/labs/imaging/treatments billed) not diagnosis codes. Maintain current appeal processes and documentation practices. No immediate action required before the effective date, but coordinate with IT/billing system vendor now to ensure system readiness.