Beginning July 1, 2021, UnitedHealthcare will enhance their capabilities to assess emergency department (ED) facility claims to determine if the ED event was emergent or non-emergent, according to existing plan provisions, in most states. Choosing the right care location may help members save.
ED claims will be evaluated based on several factors, including:
- The patient’s presenting problem
- The intensity of diagnostic services performed
- Other patient complicating factors and external causes
Claims determined to be non-emergent will be subject to limited coverage or no coverage in accordance with the member’s Certificate of Coverage. This enhanced capability will apply to commercial fully insured ED facility claims in many states for dates of service on July 1, 2021, or later. Subject to regulatory approval, UHC will continue to expand this capability to additional states and segments.
The assessment applies to both in-network (INN) and out-of-network facility emergency department claims. The states included in the program are AL, AR, AZ, CO, CT, DC, DE, FL, GA, IA, IN, KS, KY, LA, MA, MD, MI, MS, NE, NH, NJ, NV, NY, OH, OK, OR, PA, SC, TN, TX, VA, WA, WI, WV.
Effective dates are on and after July 1, 2021, on renewal for most UnitedHealthcare large group fully insured plans and on and after Jan. 1, 2022, for most small group fully insured plans on renewal.
Beginning June 1, 2021, some fully insured members will receive a reminder that emergency room visits for non-emergency care are subject to limited coverage or may not be covered for the full cost of the emergency room visit, as outlined in the Certificate of Coverage.
Providers received the information in the June Network Bulletin and on uhcprovider.com. If a claim is determined to be non-emergent, the provider may complete an attestation form to attest if the event met the definition of an emergency consistent with the prudent layperson standard.
Member will receive an Explanation of Benefits (EOB) with language describing the reason for the limited coverage for an emergency visit that is determined to be non-emergency. There are member appeal rights based on state guidelines, which are stated on the EOB.
Contact your Cornerstone representative for more information.