#emergencyroom – KR2 Medical Billing

This policy will become effective as of 07/01/2021 and will apply to commercial claims for “most states”.

The claims will be assessed according to existing plan provisions and evaluated on, including:

The patient’s presenting problem
The intensity of diagnostic services performed
Other patient complicating factors and external causes

If the claims are determined to be non-emergent than the claim will not be paid or subject to limited coverage in accordance with the member’s Certificate of Coverage.

This enhanced capability will apply to commercial fully insured ED facility claims in many states for dates of service on July 1, 2021, or later. Subject to regulatory approval we will continue to expand this capability to additional states and segments.

Attestation:

If an ED event is determined to be non-emergent, you’ll have the opportunity to complete an attestation if the event met the definition of an emergency consistent with the prudent layperson standard.

A notice of the opportunity to submit an attestation will be sent electronically to the facility when an ED event is determined to be non-emergent. Instructions about accessing the attestation through UHCprovider.com will be included. We may also follow up with a mailed letter about the attestation.

If the attestation is submitted within the required time frame, the claim will typically be processed according to the plan’s emergency benefits.

UnitedHealthcare reserves the right to order medical records for claims review, even if an attestation has been submitted.

**If provi*ders have any questions, please contact Provider Services at 877-842-3210 or your Network Representative.***

Would like to learn more about recent changes medical coding and billing guidelines? Please visit the Recent Posts:

#emergencyclaims, #UHCcommercial, #attestation, #facilityclaims

For DOS 04/01/2021 and thereafter Aetna will NO LONGER separately reimburse for treatment room services: REVENUE CODES 760/761, when billed with:

• emergency room visit
• inpatient stay
• laboratory and/or radiology services
• outpatient minor surgical or medical procedure
• outpatient observation stay
• urgent care visit

“Treatment room services are not reimbursed when billed with a
service for room charges as part of an inpatient stay, emergency
or urgent care visit, outpatient observation, outpatient minor
medical/surgical procedure, or for the sole purpose of
performing laboratory or radiology testing.”

Source: Aetna February Provider Communications

Tag: #emergencyroom

How is UHC assessing ED facility commercial claims, 07/01/2021

**If provi*ders have any questions, please contact Provider Services at 877-842-3210 or your Network Representative.***

Aetna and payment for treatment room services (effective 04/01/2021)

If providers have any questions, please contact Provider Services at 877-842-3210 or your Network Representative.

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**If provi*ders have any questions, please contact Provider Services at 877-842-3210 or your Network Representative.***