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Criteria for Reimbursement of Emergency Room Services


Services that are performed in the emergency room (ER)/emergency department (ED) setting are reimbursed to participating professional providers and/or to the participating facility in which the services are provided. The Company applies the definition of emergency and diagnostic criteria to determine the appropriate level of reimbursement for these services.

In accordance with the facility and/or professional provider contracts, the following reimbursement methodologies may be applied to facility claims and claims submitted by professional providers who specialize in emergency medicine:

  • Eligible emergent services may be reimbursed at an emergency level.
  • Eligible services that are not considered emergent may be reimbursed at a triage level (i.e., a reduced rate).
For all other Company products, medically necessary ER/ED services are covered and eligible for reimbursement consideration as outlined in the applicable participating professional provider contract or participating facility contract.


The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.


This policy is consistent with Medicare's coverage determination for emergency room services. The Company's payment methodology may differ from Medicare.


Subject to the terms and conditions of the applicable Evidence of Coverage, emergency room service is covered under the medical benefits of the Company's Medicare Advantage products.



Reimbursement eligibility for services rendered in an emergency room (ER)/emergency department (ED) setting to participating professional providers and/or to participating facilities is based on diagnostic criteria, the definition of emergency, and all applicable facility provider and/or professional provider contract terms.

Emergency is defined as the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any one of the following:
  • The health of the individual being placed in serious jeopardy
  • The health of a pregnant woman or her unborn child being placed in serious jeopardy
  • Serious impairment to the individual's bodily functions
  • Serious dysfunction of any of the individual's bodily organs or parts
Medical emergency situations include, but are not limited to:
  • Heart attacks, strokes, poisoning, loss of consciousness or respiration, and convulsions
  • Accidents such as, but not limited to, falls, severe cuts, broken bones, and other traumatic bodily injuries

When the individual's condition does not meet diagnostic criteria or the definition of emergency, the participating facility and/or participating professional provider, in accordance with the applicable provider contract, may receive a reduced level of reimbursement. This reduced level of reimbursement is referred to as a triage rate or triage level of reimbursement.


Centers for Medicare & Medicaid Services (CMS). Emergency Medical Treatment and Labor Act Technical Advisory Group (EMTALA TAG).[CMS Web site]. 03/26/2012. Available at: Accessed October 28, 2022.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections: 20.2 – Definitions of Emergency and Urgently Needed Services. [CMS Web site]. Available at: Accessed October 28, 2022.

Commonwealth of Pennsylvania. Title 28: Health and Safety. Part I: General Health. §9.602: Definitions, emergency service. [The Pennsylvania Code Web site]. 06/09/01. Available at: Accessed October 28, 2022.

Commonwealth of Pennsylvania. Title 28: Health and Safety. Part VII: Emergency Medical Services. §1001.2: Definitions, emergency medical services (EMS). [The Pennsylvania Code Web site]. 02/07/04. Available at: Accessed October 28, 2022.

Company Provider Manuals.

Evidence of Coverage.

New Jersey Department of Banking and Insurance. Health Insurance Programs: Individual Health Coverage Programs. Small Employer Benefits Programs. [New Jersey Department of Banking and Insurance Web site]. Available at: Accessed October 28, 2022.

New Jersey Legislature. Assembly Health Committee Statement To Assembly, Bill No. 2829. [New Jersey Legislature Web site]. 02/23/2015. Available at: Accessed October 28, 2022.


CPT Procedure Code Number(s)
99281, 99282, 99283, 99284, 99285, 99291, 99292

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)

HCPCS Level II Code Number(s)

Revenue Code Number(s)
0450 Emergency Room - General

0451 Emergency Room - EMTALA Emergency Medical Screening Services

0452 Emergency Room - ER Beyond EMTALA

0456 Emergency Room - Urgent Care

0459 Emergency Room - Other Emergency Room

0681 Trauma Response - Level I

0682 Trauma Response - Level II

0683 Trauma Response - Level III

0684 Trauma Response - Level IV

0689 Trauma Response - Other Trauma Response

0981 Professional Fees - Emergency Room

Coding and Billing Requirements

Policy History

Claim Payment Policy Bulletin
Medicare Advantage