Start free

PolicyChanges tracks payer policy changes for medical practices and tells you what to do before they take effect.

Create a free accountPolicy Monitoring is free. No card required.
← Back to list
AmbetterExchange · Billing Codes · Coding · Emergency MedicineHigh impact

Provider Notification: Cotiviti ED Leveling - Facility

Act
by Oct 31, 2026
Effective date
Nov 1, 2026
Identified
Sep 30, 2026

Summary

Effective November 1, 2026, Ambetter Health will implement ED leveling for facility-based Emergency Department E&M services, applying national CPT billing guidelines to recede overcoded facility E&M levels. Facility E&M codes will be reimbursed based on resources utilized (nursing time, clinical staff, supplies, equipment) rather than physician cognitive work. This affects facility charges across Medicare, Marketplace, and Medicare-Medicaid plans.

Get alerts when payers change rules like this one

We check Ambetter and other payers every day and email you when a change matches your specialty and state.

Get Ambetter alertsPolicy Monitoring is free. No card required.

What to do

by Oct 31, 2026 · 5 steps
01Billing team must review and update facility ED E&M coding practices to align with national CPT guidelines for resource-based leveling.
02Update billing system configuration to apply resource-based E&M level determination for facility charges (not professional charges) in the billing system.
03Educate providers and clinical staff on the distinction between facility resource utilization versus physician cognitive work in E&M coding.
04Review current ED claim submissions for potential overcoding and implement corrective measures to prevent claim recapture or downgrade.
05Implement peer risk adjustment review process to ensure facility E&M codes are leveled to the highest appropriate code level.
If missed: Failure to comply may result in claim denials, recoupment of overpayments, or inclusion in high-coding practitioner monitoring programs.

Original notice

Provider Notification: Cotiviti ED Leveling - Facility
ambetterhealth.com · Always check the source before changing claims.
View original ↗

Related changes

See all Ambetter changes →
Effective November 1, 2026, Ambetter Health will apply national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.HighEffective Nov 1, 2026 · CodingLeveling of Care: Emergency Department Evaluation and Management Overcoding for Facility ServicesHighEffective Sep 28, 2026 · CodingBrowse every Ambetter change in the policy list

Related policy hubs

Ambetter policiesEmergency Medicine

Summaries are AI-assisted. Always confirm against the original payer notice.

What is PolicyChanges

One workspace for payer rules, prior auth, coding and compliance

Medical practices use PolicyChanges to catch payer changes before they cause denials. Every change is summarized in plain English, with the codes involved, the date it takes effect and what to do.

Policy MonitoringPayer policy, prior auth and coding changes, filtered to your saved searchesOIG ScreeningStaff and vendors screened every month against OIG LEIE, SAM.gov and state Medicaid listsPrior Auth LookupKnow if a service needs prior authorization before you schedule itCredentialing TrackerLicenses, CAQH, Medicare revalidation and payer enrollments, with reminders before anything lapsesCompliance CenterKeep your HIPAA program documented and ready to show
Start freePolicy Monitoring is free. No card required.
Get alerts for changes like thisPolicy Monitoring is free. No card required.Create a free account