Oakland Southfield Physicians

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Blue Cross Complete Emergency Services Level of Care Review Policy

Posted: 08/25/2020

All claim diagnoses will be considered for determination of consistency with the Level 4 or 5 ED E&M service that was billed. Determinations of inconsistency between diagnosis severity and level of care will be made against the “NYU Emergency Room Algorithm” diagnosis list, which is routinely evaluated and modified by the Blue Cross Complete medical director participating in the clinical review.

Inconsistent claim billing is suspected when the supporting diagnoses would not require the three key components necessary to support ED E&M service Level 4 or Level 5 (as defined in the explanations for CPT codes 99281-99285 found in the CPT Manual maintained by the American Medical Association).

The emergency services claim is not being evaluated for lack of emergency criteria and can be rebilled with a more appropriate level of care.


ED claims will be exempt from recovery when any of the following scenarios exist in the member’s claim history within three days of the ED visit date of service:

  • Any room board revenue code (100-219)
  • Any Operating Room revenue code (360-369)
  • Any trauma revenue code (681-689)
  • Any observation revenue code (760-769)
  • Any cardiology revenue code (480-489)

Facility providers or practitioners contracting with any of Blue Cross Complete’s Medicare or Medicaid plans using a bundled or case rate payment method for ED services will be exempt from the review and recovery process.

Reimbursement guidelines

Blue Cross Complete will reimburse according to the applicable Michigan Medicare Fee Schedule and the provider’s contract.

Professional and facility claims that meet defined requirements for claim submission (see section 13 of the Blue Cross Complete Provider Manual for detail), and that are appropriately coded based on all other applicable ICD-10, CPT or CMS standards, will be reimbursed to the provider. After reimbursement, both professional and facility ED claims billing Level 4 or Level 5 services will be reviewed against the “NYU Emergency Room Algorithm” diagnosis list for severity of diagnosis. If diagnosis severity isn’t consistent with the level of service billed, Blue Cross Complete will pursue recovery of the claim payment. The provider will receive a standard recovery letter and may:

  • Resubmit the claim for the services using a corrected claim, according to plan-defined corrected claim process, coding the appropriate level of care.
  • Dispute the recovery utilizing the plan-defined provider dispute process.

If neither of the above actions occur, previously reimbursed funds will be recovered according to the existing Blue Cross Complete Program Integrity recovery process.

Details of the corrected claim, claim dispute and Blue Cross Complete Program Integrity recovery processes can be found in the Blue Cross Complete Provider Manual at mibluecrosscomplete.com.


If you have questions, contact your Blue Cross Complete provider account executive or call Blue Cross Complete Provider Inquiry at 1-888-312-5713.


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