Back to Insights and Updates for ProvidersJune 2024

Updates to facility ER policy and processing rules

All products

Beginning Aug. 1, 2024, Point32Health will begin reviews of facility ER claims for Harvard Pilgrim Health Care and Tufts Health Plan products to determine the appropriateness of the evaluation and management level of care submitted.

We will evaluate claim data for emergency department visit procedure codes billed to determine if the procedure code submitted is consistent with the intensity of the resources filed by the facility.

Through an assessment of the following information as documented on the claim, if Point32Health determines that the facility level of care billed is not supported based on these factors, the facility may receive a denial for the ED visit code level submitted:

  • Presenting problem/s, which is identified by the ICD-10 reason for visit diagnosis
  • Diagnostic services performed, based on the intensity of the diagnostic workup and measured by the submitted CPT codes (such as lab work, x-ray, EKG, or CT/MRI/ultrasound)
  • Patient complexity and co-morbidity, which is based on the complicating condition as defined by the principal, secondary, or external cause of injury ICD-10 diagnosis codes

Denied claims will need to be resubmitted with a supported code for reprocessing.

For more information, please refer to Point32Health’s Emergency Department Services Payment Policy, which we have updated to reflect the above-referenced change.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Ellen Gustavson, Ryan Francis, Stephen Wong,

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