MedicaidReimbursementHigh impact
[Ohio] New reimbursement policy: Emergency Department: Leveling of Evaluation and Management Services
Anthem BCBS·OH · Emergency Medicine·Claims & Billing
Effective date
Nov 1, 2026
We identified it
Aug 3, 2026
Summary
Anthem Ohio Medicaid is implementing a new ED E/M leveling policy effective November 1, 2026, that will validate submitted E/M code levels based on documented intensity and complexity of resources/interventions. Claims with E/M codes higher than supported by documentation will be subject to denial, resubmission requests, downward adjustment, or recovery of overpayments. Providers must ensure accurate E/M coding supported by comprehensive documentation of facility interventions.
Action Required
Before November 1, 2026: (1) Billing team must implement validation procedures to ensure ED E/M codes submitted match the documented intensity/complexity of facility interventions on each claim. (2) Providers must review and update ED encounter documentation templates and workflows to clearly capture and reference all facility interventions performed (resource intensity and service complexity). (3) Establish internal audit process to validate E/M code selection against documentation before claim submission. (4) Train billing and clinical staff on the new policy requirements and documentation standards. (5) Update claim submission procedures to flag potential E/M code misalignment for manual review before transmission to Anthem. Failure to comply will result in claim denials, resubmission requirements, downward reimbursement adjustments, and potential recovery/recoupment of previously paid amounts.