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AmbetterExchange · Reimbursement · Provider Bulletin · MO · Emergency MedicineHigh impact

Emergency Department Facility E/M Leveling Update (PDF)

Act
by Sep 15, 2026
Effective date
Sep 15, 2026
Identified
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.

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What to do

by Sep 15, 2026 · 6 steps
01Billing team must transition ED facility E/M claim processing from the Optum EDC Analyzer to the Cotiviti leveling system.
02Verify 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.
03Confirm that claims cannot be adjusted below Level 3 (CPT 99283/G0382) in system settings.
04Brief ED coding and billing staff that the new vendor uses resource-consumption methodology (services/labs/imaging/treatments billed) not diagnosis codes.
05Maintain current appeal processes and documentation practices.
06No immediate action required before the effective date, but coordinate with IT/billing system vendor now to ensure system readiness.

Codes mentioned

9928199282992839928499285G0380G0381G0382G0383G0384

Original notice

Emergency Department Facility E/M Leveling Update (PDF)
ambetterhealth.com · Always check the source before changing claims.
View original ↗

Related policy hubs

Ambetter policiesMO policy changesEmergency MedicineCode 99281Code 99282Code 99283Code 99284Code 99285Code G0380Code G0381Code G0382Code G0383Code G0384

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