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- Each nursing or technical intervention needs a chargeable line to be counted
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Insight · Anthem facility reimbursement policy G-19002
Anthem's ED leveling policy G-19002: what to audit before the recoupment letter
Short answer: Anthem sets the facility ED E/M level by classifying the intensity and complexity of the interventions and resources shown on the claim, and reserves the right to deny, adjust or recoup. Charge capture is the defense; the evidence file is the insurance.
G-19002 · Facilities section
CA Medi-Cal copy · effective Apr 24, 2020
4 exclusions
Recoupment · back to the effective date
Focus
Anthem G-19002
Payers
Anthem
Audience
Hospital ED
Codes
Facility ED E/M
Effective date
Apr 24, 2020 (CA)
Length
5 min read
3actions
Deny and request resubmission or records, adjust to the lower level, or recoup prior payments [1]
4exclusions
Critical care or outpatient surgery during the visit, death in the ED, admission or transfer, observation [1]
Jan 162024
Last approval date on the California Medi-Cal version, reviewed with no changes [1]
3words
"On the claim": an intervention with no charge line is invisible to the classification
One policy, published by state and line of business
This read uses the California Medi-Cal text [1]; pull your own state's G-19002 first.
Intensity and complexity of resources, as indicated on the claim
Anthem classifies "the intensity and/or complexity of resources or interventions a facility uses to furnish all services indicated on the claim" [1].
Resources
Building, equipment, supplies
- Room type, monitoring and supplies show up through revenue codes and HCPCS
Intensity and complexity
Quantity, type, specialization
- Plus presenting problem, member age, acuity and diagnostic services, as indicated on the claim
Professional services
Not counted
- The physician's MDM does not raise the facility level under this policy
Emergency services
Prudent layperson
- Includes severe pain and pregnancy; cite alongside 45 CFR 149.110 in any appeal
Three actions, one evidence file
A UHC adjustment shows on the remit; an Anthem recovery can arrive after the cash is booked, back to the policy's effective date [1].
Action 1Deny and request resubmission or records
Resubmit at the appropriate level, or send documentation supporting the level billed.
ResponseDecide once: corrected claim if a line or code was missing; records if the claim was complete.
or
Action 2Adjust reimbursement
Pay at the lower ED E/M classification.
ResponseReconsideration with the itemized claim and the nursing record.
or
Action 3Recover or recoup
Take back amounts paid above the supported level.
ResponseContest within the contract's recoupment window; supply the same evidence file.
Takeaway
Keep the claim-level evidence file for the full recoupment look-back. The appeal you may need is the one that arrives after the account closed.
G-19002 against UHC's two facility policies, exclusion by exclusion
| Exclusion | Anthem G-19002 (CA Medi-Cal) | UHC 2026R6003A | UHC 2026R6007A |
|---|---|---|---|
| Critical care during the visit | Yes | Yes | Yes |
| Outpatient surgery during the visit | Yes | Yes | Yes |
| Member expired in the ED | Yes | Yes | Yes |
| Admitted inpatient or transferred | Yes | Yes (admitted; discharged or transferred) | Yes (admitted) |
| Observation status | Yes | Not listed | Yes |
| Under 2 years old | Not listed | Yes | Yes |
| High-resource diagnoses | Not listed | Yes | Yes |
G-19002 [1], UHC 2026R6003A [2], UHC 2026R6007A [3]; Anthem also adheres to EMTALA
Listed exclusions per policy, out of the seven that appear in any of the three
Patient status does different work by payer. Detail: the leveling defense white paper and the UHC EDC Analyzer read.
Anthem G-19002CA Medi-Cal
4 of 757%
UHC 2026R6003Acommercial and exchange
6 of 786%, no observation
UHC 2026R6007AMedicare Advantage
7 of 7100%
02467
AnthemUHC
Six checks before release
- 1
Intervention-to-charge map
- Every intervention in the leveling guideline has a CPT, HCPCS or revenue code line, and the audit proves it posted
- 2
Presenting problem and acuity on the claim
- Reason-for-visit coding and triage acuity captured as coded data, not free text
- 3
Age and diagnostic services
- Date of birth correct
- Every resulted diagnostic service on the claim
- 4
Patient status and disposition
- Observation, admission, transfer and expired right before release; each is an exclusion
- 5
Critical care minutes billed
- Delivered facility critical care documented and billed; it removes the claim from scope
- 6
Level distribution by month
- Paid versus billed mix on Anthem volume; a classification change shows before the letter does
Four moves on Anthem facility volume
Pull your state's G-19002Published by state and line of business.
Test a quarter of level 4 and 5 claimsOur emergency department billing services team runs Anthem and UHC audits together.
Put level rules at the submit gateOur denial prediction engine scores level 4 and 5 claims against payer rules.
Build the evidence file for the look-backAppeal letter: ED downcoding appeals guide.
Frequently asked questions
What is Anthem reimbursement policy G-19002?
Anthem's facility reimbursement policy for Emergency Department Leveling of Evaluation and Management Services. Anthem classifies the intensity and complexity of the resources and interventions shown on the claim, and may deny, adjust or recoup when the billed level is higher than that classification. The California Medi-Cal version was initially effective April 24, 2020 and last approved January 16, 2024.
What does Anthem do when it decides the billed ED level is too high?
The policy lists three options: deny the claim and request resubmission at the appropriate level or documentation supporting the level billed; adjust reimbursement to the lower classification; or recover and recoup amounts previously paid above the supported level.
Which claims are excluded from Anthem's ED leveling policy?
Four exclusions are listed: critical care or outpatient surgery performed during the ED visit, a member who expired in the ED, a member admitted inpatient or transferred to another facility, and a member placed in observation status.
Does the physician's documentation raise the facility level under G-19002?
Not directly. The policy's definitions state that professional provider services are not considered facility interventions or resources; the facility level is classified from staff work, equipment, supplies, presenting problem, member age, acuity and diagnostic services on the facility claim.
- Anthem Blue Cross, California Medi-Cal Managed Care Reimbursement Policy G-19002, Emergency Department Leveling of Evaluation and Management Services (last approval January 16, 2024; document code CABC-CD-RP-057609-24, July 2024)
- UnitedHealthcare Commercial and Individual Exchange Reimbursement Policy 2026R6003A, ED Facility E&M Coding Policy (for the exclusion comparison)
- UnitedHealthcare Medicare Advantage Reimbursement Policy 2026R6007A, ED Facility E&M Coding Policy (for the exclusion comparison)
Checked October 25, 2026. Rules and payer policies change; confirm against the source before relying on them.
ServiceEmergency department billing services
White paperED facility E/M leveling defense
InsightUHC's EDC Analyzer policies: 2026 read
BlogED downcoding appeals and the prudent layperson standard
NewsletterCritical care 99291 documentation that pays
TechnologyPre-submit denial prediction
ServiceEmergency room billing services
Running Anthem facility ED volume without a level audit?
We map interventions to charge lines, test a quarter of level 4 and 5 claims against the policy, and set up the evidence file that answers a recoupment letter.