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.
REQUIRED DOCUMENTATION
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.
