Date Issued: 8/5/2014
EmblemHealth continues its commitment to correct coding and the implementation of programs that result in fair, widely recognized and transparent payment policies. Beginning September 1, 2014, EmblemHealth will evaluate the appropriateness of Evaluation and Management (E&M) service levels for HIP, GHI HMO and Vytra, using recognized policy sources* to ensure they are supported by the American Medical Association’s E&M documentation criteria.
As of March 27, 2018, EmblemHealth has expanded the program to include GHI PPO. Based on the outcome of this evaluation, your payment may be adjusted if the information submitted does not support the level of service billed.
To avoid any payment adjustments, we recommend you carefully document each service provided, according to the CMS guidelines: Documentation Guidelines for Evaluation and Management. Complete medical record documentation is the foundation of every patient's health record and can significantly affect claims coding and adjudication. Accurate coding translates clinical documentation into uniform diagnostic and procedural data sets and provides the evidence that the services billed were rendered to the patient.
Disputing a Claim Determination
If you do not agree with a payment determination, you have the right to file a grievance. You must first submit the portion of the medical record that supports additional reimbursement. We will review the submitted medical record(s) to assess the intensity of service and complexity of medical decision-making for the E&M services provided. EmblemHealth will adjust those claims where documentation substantiates the provision of a higher level of E&M service.
For additional details on grievance rights, refer to the “Practitioner Dispute Resolution Procedures: Complaints and Grievances” sections of the EmblemHealth Provider Manual. Please review the chapter that applies to the member’s benefit plan:
- Commercial and Child Health Plus Plans
- Medicaid Managed Care and Family Health Plus Plans
- Medicare Plans
If you have questions, please sign in to our website. Go to the Message Center. Select “General Information” from the drop-down menu on the “Ask a Question” page.
* Policy sources include, but are not limited to, the requirements of CMS, AMA, other specialty academies’ policies and procedures, as well as EmblemHealth’s plan-specific requirements. (Refer to the Claims Review Software section of the Claims chapter of the EmblemHealth Provider Manual for additional information about claims review software used by EmblemHealth.)