Summary
Ambetter from WellCare of Kentucky will apply national CPT guidelines to the coding of outpatient emergency department E&M levels for facility claims beginning 12/06/2026. Under the payer's comparative peer risk adjustment process, E&M claim lines will be recoded to the corrected level, with reimbursement at the highest level whose criteria are met, based on facility resources such as nursing time, clinical staff effort, supplies, equipment, and overhead rather than provider cognitive work. The payer's policy CC.PP.80 replaces the previous Optum EDC Analyzer.
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What to do
Action · 3 steps
01By 2026-12-06: Billing team, review outpatient ED facility E&M charge entry for Ambetter from WellCare of Kentucky members and confirm each level is supported by documented facility resources, including nursing time, clinical staff effort, supplies, equipment, and overhead directly related to care.
02Brief providers and front desk staff that ED facility levels for these members will be recoded by the payer, and compare upcoming claims against the payer's policy CC.PP.80 (Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services).
03Track the payer's denial code EXLc on returned claims so the team can see which lines were recoded, and where a recoded level is disputed, gather the facility documentation supporting the original level and prepare it for appeal or corrected resubmission.
Original notice
Leveling for Facility Claims
ambetterhealth.com · Always check the source before changing claims.