Effective September 1, 2023, Highmark will begin auditing outpatient Emergency Department facility claims to ensure the correct procedure codes are being billed.

Originally, audits were to begin on May 1, 2023. However, due to additional updates to Reimbursement Policy (RP)-037: Emergency Evaluation and Management Coding Guidelines, the effective date for the audits has been moved until September 1, 2023.

These audits are designed to determine the appropriate and fair level of facility reimbursement for emergency department services based on the Centers for Medicare and Medicaid Services (CMS) criteria for the appropriate procedure code. Highmark will review the diagnoses submitted, as well as the services performed to ascertain the appropriate level of care for the visit, on a scale of one (1) through five (5).

The auditing process may result in a different reimbursement than expected, with Highmark updating the procedure code listed on the claim to the correct procedure code.

On May 1, 2023, Highmark updated and republished RP-037 with a full description of these changes.

How to Determine If Your Claim Was Changed

If the audit determines your claim warrants the level of care at which the claim was billed, the claim will not be changed. If we determine the claim warrants a different level of care, Highmark will add a new line with the correct procedure code and reimburse you at the updated rate.

If Highmark lowers your level of care, you will be able to see the new procedure code on the Explanation of Benefits (EOB). The code you originally submitted on the claim and the code Highmark added to the claim will be stored in our systems for CMS audits. However, the EOB will only show the corrected procedure code.

To view EOBs via NaviNet^® , select AR Management from the left menu and then click EOB and Remittance from the fly-out menu.

Appealing the Updated Rate

If you disagree with the level of care that Highmark determined through the audit, you can file an appeal with Highmark. To appeal, you will need to submit all related medical records to Highmark’s Medical Review team as outlined in the Highmark Provider Manual’s Chapter 5, Unit 5: Denials, Grievances & Appeals.

To locate the Highmark Provider Manual, hover over MANUALS in the quick access bar at the top of the Provider Resource Center and select HIGHMARK PROVIDER MANUAL.