Claim Editing Changes for Emergency Department Services Coming Nov. 1, 2023

July 31, 2023

We’re enhancing our claims editing and review process with Cotiviti for emergency department evaluation and management services for some of our commercial members. Editing changes for applicable facility and professional claims will take effect beginning Nov. 1, 2023, to help ensure accurate billing and proper reimbursement.

What’s changing? 
Effective for claims with dates of service on or after Nov. 1, 2023
, when we review your claim: if we can’t validate the level of E&M services billed, your reimbursement will be for a lower level of service. Blue Cross and Blue Shield of Illinois (BCBSIL) follows the American Medical Association guidelines for level of service and medical decision-making.

What happens next?
If you agree with the level of service reimbursed, no further action is needed. If you don’t agree with the level of service reimbursed, you may submit additional medical records to support your claim. 

Learn More:
For more information, please refer to our Clinical Payment and Coding Policies page where you’ll find our revised CPCP003 Emergency Department Evaluation and Management (E/M) Services – for Facility Services policy and our new CPCP042 Emergency Department Evaluation and Management (E/M) Services Coding – for Professional Services policy.

This information doesn’t apply to government programs (Medicare Advantage or Illinois Medicaid) claims.

Cotiviti, INC. is an independent company that provides medical claims administration for BCBSIL. Cotiviti is solely responsible for the products and services that it provides.