Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 02|15|2011 POLICY LAST REVIEWED: 03|06|2024

OVERVIEW The intent of this policy is to identify services that are included in an emergency room visit payment rate.

MEDICAL CRITERIA Not applicable.

PRIOR AUTHORIZATION
Not applicable.

POLICY STATEMENT Emergency medical services for participating providers, are reimbursed at a per visit rate include, but are not limited to:  Durable medical equipment (e.g., Bandages, crutches, canes, collars, and other supplies)  Laboratory services  Medication  Radiology services  CT Scans

MRI's:  MRA/MRI's are separately reimbursed and excluded from the emergency room visit rate.

Observation Services:  If the member goes to the Emergency Room and is later admitted for observation status, both the Emergency Room and Observation Rates are reimbursed (refer to Blue Cross' Observation Services payment policy for additional information).

Professional Services:  Professional services are separately reimbursed and not included in the facility rate.

Surgical Procedures (Facility):  If the surgical procedure is performed in the Emergency Room, then there is no separate surgical reimbursement for the facility, and only the Emergency Room facility rate is paid.  If the surgical procedure is performed in the Operating Room, then the surgical case rate is paid in addition to the Emergency Room payment rate.

Other services: All other services are contract specific

COVERAGE Reimbursement for emergency medical services may vary between hospital contracts. Applicable copayments will be applied.

Payment Policy | Emergency Room Reimbursement

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

BACKGROUND Not applicable.

RELATED POLICIES None

PUBLISHED Provider Update, May 2024 Provider Update, April 2021 Provider Update, December 2018 Provider Update, January 2011

REFERENCES None

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS