Claim Editing Changes for Emergency Department Services Coming November 1, 2023 

July 27, 2023

Blue Cross and Blue Shield of Montana (BCBSMT) plans to enhance our claims editing and review process or emergency department (ED) evaluation and management (E&M) services for our commercial members. These editing enhancements, effective on November 1, 2023, will apply to both facility and professional claims and will help ensure accurate billing and reimbursement.

What’s changing:  You may receive a lower level of reimbursement if we cannot validate the level of E&M services billed, based upon the information provided with your claim. We follow 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 do not agree with the level of service reimbursed, you may submit additional medical records to support your claim.

Learn More: For more information on revisions to our ED claims editing, please review our Coding and Compensation Policies in Availity® Essentials by using the Plan Documents Viewer application in our BCBSMT-branded Payer Spaces section. Look for our revised Emergency Department Evaluation and Management (E/M) Services – for Facility Services policy and our new Emergency Department Evaluation and Management (E/M) Services Coding – for Professional Services policy.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.