Emergency Department Claim Analyzer reminder and reconsideration program

As a reminder, the Emergency Department Claim Analyze, or EDCA, program was re-implemented on June 1, 2024, in conjunction with a new Emergency Department Facility Evaluation and Management reimbursement policy. This reimbursement policy was developed to ensure that facilities are reimbursed based on the consistent coding that correctly describes the patient’s clinical condition and the health care services provided in accordance with industry standards and Centers for Medicare & Medicaid Services guidelines.

What does this mean to hospitals?

Blue Cross is reviewing evaluation and management, or E/M, claims that are billed with a level four or five E/M code (*99284 or *99285) for the appropriate level of care on a prepayment basis. Claims that don't meet the policy criteria will be adjusted and reimbursed at the appropriate level.

At this time, claims that are two or more levels higher than the Blue Cross reimbursement policy will be adjusted. Claims that are one level higher won't be adjusted. Blue Cross will continue to monitor all emergency department claims submitted. We reserve the right to modify the scope if adherence and adjustments don't align with the reimbursement policy.

Hospitals reimbursed by the fee schedule

For hospitals reimbursed via the fee schedule, claims recommended for adjustment will be adjusted to the appropriate level. These claims will be paid according to the fee schedule requiring no additional action by the hospitals. The change will be reflected in the provider voucher and 835 electronic transaction. This will also be shown with a CO186 adjustment code, level of care change adjustment.

Hospitals reimbursed by percent of charge

For hospitals reimbursed percent of charge, emergency department claims recommended for adjustment will be denied. Remittance will be provided with information on how to be reimbursed and will indicate the appropriate level recommended for approval. It will require hospitals to adjust the claim and charges associated and re-submit to Blue Cross for processing and payment.

What should I do if I am a percent of charge hospital, and my claim was denied?

You can submit a corrected claim through either:

• Availity.com**
• 837 electronic transaction
• Please ensure that the last position of the Type of Bill, reported in Loop 2300 CLM05, reflects the appropriate "Claim Frequency Type" code in the CLM05-3 data element, as per NUBC billing guidelines

What should I do if I disagree with the claim adjustment?

Providers who disagree with the claim adjustment have the right to submit a reconsideration request to have their claim reviewed. To have the claim reviewed, providers must supply:

• Explanation of how the adjusted claim meets Blue Cross’ reimbursement policy criteria
• Specific CMS guidelines met to justify a higher level
• Medical record documentation

If these items aren't provided, the claim will remain adjusted/denied and the reconsideration will be upheld.

To submit a reconsideration using Availity, please complete the following steps:

1. Log in to Availity.com.**
2. On the Claims & Payments menu, click Claim Status and follow the prompts to locate the claim for which you want to appeal a clinical editing denial.
3. On the claim, click Claim Dispute. This initiates the appeal.

Note: If you want to initiate appeals on additional claims, click Close to return to the Claim Status results page. To continue your appeal of the claim in question, complete the additional steps outlined here.

4. Click Go to Request to open the Appeals application and access the request in “Initiated” status.
5. On the action menu at the top right of the claim, click Complete Dispute Request.




6. In the dialog box that opens:
1. Enter data into the fields.

Important: In the field shown below, enter this information:

• What you are appealing
• Your reason for appealing
• Your return address (that is, an address to which we can send a determination letter through the U.S. mail)



2. Click Add File and upload the relevant documentation.
3. Click Submit Request.
Your request will be sent for processing by the Blue Cross / BCN clinical editing staff.

The Emergency Department Facility Evaluation and Management Reimbursement Policy can be found on the Provider Resources website:

1. Log in to the Blue Cross Blue Shield of Michigan provider portal (Availity.com).**
2. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
3. Click the Resources tab.
4. Click Secure Provider Resources (Blue Cross and BCN).
5. Click Billing and Claims on the menu bar and then click Codes and Criteria.
6. Scroll down to the Clinical Editing section and click on Emergency Department (ED) Facility Evaluation and Management (E/M) Coding Policy.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.