New Facility Emergency Department E&M Services Reimbursement Policy

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is implementing a new policy for our Facility Emergency Department (ED) Evaluation and Management (E&M) Services effective May 1, 2024, following Blue Cross NC’s notice published March 1, 2024. Please review the full policy here for commercial (PDF) and here for Medicare Advantage (PDF).

The new reimbursement policy defines Blue Cross NC’s reimbursement guidelines for facility interventions and resources expended during ED services. Facility ED E&M reimbursement is based on the intensity and/or complexity of facility interventions and resources expended, as indicated on the claim. If the E&M service billed does not align with the facility resources expended, the claim may be denied, and providers can resubmit with the more appropriate E&M. Providers may request reconsideration per the appropriate form located here.

This policy applies to Commercial, Medicare Advantage including Experience Health, Federal Employee Program (FEP), IPP Host and State Health Plan (SHP).  This policy is not applicable to IPP Home.  

Please call Provider Services (800-214-4844) for any questions regarding this policy.