MedicaidReimbursementMedium impact
Provider Letter 2025-08: RE: Emergency Room (ER) Evaluation and Management (E/M) Leveling Program
Oklahoma SoonerCare·OK · Emergency Medicine·Provider Letter
Effective date
Apr 1, 2025
We identified it
Jun 20, 2026
Summary
Humana Healthy Horizons in Oklahoma (Medicaid managed care) will implement an ER E/M leveling program starting April 1, 2025, where they will downcode and pay at lower E/M levels if facility charges don't support the higher billed E/M codes based on defined criteria. This affects reimbursement for emergency department evaluation and management services for SoonerSelect Medicaid members.
Action Required
Before April 1, 2025: Emergency department billing teams must ensure accurate E/M coding documentation supports the level billed for Humana Healthy Horizons Oklahoma Medicaid members. Review current ER E/M coding practices and documentation requirements to prevent downcoding and reduced reimbursement. Contact Humana at 855-223-9868 or OKMedicaidProviderRelations@humana.com for specific criteria details.