Reminder: New Updates to Claim Editing Changes for Emergency Department Services 

Updated February 26, 2024
Updated December 21, 2023
Originally Posted October 24, 2023

Blue Cross and Blue Shield of Montana is enhancing its claims editing and review process with Cotiviti for emergency department evaluation and management services for our commercial members.

As we told you last year, for dates of service beginning Nov. 1, 2023, we began editing applicable professional claims to help ensure accurate billing and proper reimbursement.

Now, for dates of service beginning April 1, 2024, we will edit applicable facility claims to help ensure accurate billing.

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

Cotiviti, INC. is an independent company that provides medical claims administration for BCBSMT. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.

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.