The quiet row
A facility whose level 4 and 5 mix already tracks the analyzer is not adjusted; the adjustment rate is the measure to manage.
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Insight · UnitedHealthcare ED facility E/M, September 2026 versions
UHC's EDC Analyzer policies for ED facility E/M: what the 2026 versions say
Short answer: two policies, both changed September 1, 2026, re-level level 4 and 5 UB-04 claims from three inputs on the claim. Most adjustments trace to a missing input, not the chart. Audit the claim first.
2026R6003A · commercial and Exchange
2026R6007A · Medicare Advantage
99284 · 99285 · G0383 · G0384
Optum EDC Analyzer · Calculated Visit Level
Focus
UHC EDC Analyzer
Payers
UnitedHealthcare
Codes
99284 · 99285 · G0383 · G0384
Metric
3 inputs
Effective date
Sep 1, 2026
Length
6 min read
2policies
2026R6003A (commercial and Exchange) and 2026R6007A (Medicare Advantage), both changed September 1, 2026 [1]
3inputs
Reason-for-visit diagnosis, diagnostic CPT intensity, and complexity diagnoses produce the Calculated Visit Level [1]
9exclusions
Criteria that may take a level 4 or 5 claim out of scope; one difference between the lists [2]
30claims
Adjusted claims our quarterly audit tests against inputs and exclusions
The two policies at a glance
| Item | Commercial and Individual Exchange | Medicare Advantage |
|---|---|---|
| Policy number | 2026R6003A [1] | 2026R6007A [2] |
| Latest history entry | September 1, 2026, anniversary review, version change | September 1, 2026, version change, resources updated |
| Claim form | UB-04 or electronic equivalent | UB-04 or electronic equivalent |
| Facilities in scope | Network and non-network facility EDs, including freestanding EDs | Network provider services, all Medicare Advantage products |
| Codes listed | 99284, 99285, 99291, 99292, G0383, G0384 | 99284, 99285, 99291, 99292, G0383, G0384 |
| Decision tool | Optum EDC Analyzer | Optum EDC Analyzer |
Three factors from the claim, one calculated level, three outcomes
Neither policy reads the nursing record or physician note at the first decision [1] [2].
Input 1 · presenting problemReason-for-visit diagnosisICD-10 code in form locator 70
Input 2 · diagnostic servicesDiagnostic CPT lines, four groupsLab; X-ray; EKG, RT and other diagnostic; CT, MRI and ultrasound
Input 3 · complexityPrincipal and secondary diagnosesCommercial adds external cause of injury codes
Optum EDC AnalyzerCalculated Visit LevelCompared with the billed level 4 or 5
Both policiesAdjustPay at the calculated level instead of the billed level 4 or 5
Both policiesDenyDeny the code level submitted; the facility resubmits or appeals
Commercial onlyEstimateEstimate payment for the adjusted code from historical claims, then adjudicate a resubmitted claim on new charges [1]
Charge master note: the estimate is built from your own claims history, so finance should know which facilities UHC treats this way.
Takeaway
A complete claim is the first appeal. UHC's own Q&A says a facility that left off relevant diagnosis codes can resubmit with the codes that support the level it billed.
Nine criteria that may exclude a claim
| Exclusion | 2026R6003A commercial | 2026R6007A Medicare Advantage |
|---|---|---|
| Admitted to inpatient | Yes | Yes |
| Placed in observation | Not listed | Yes |
| Outpatient surgery during the same ED visit | Yes | Yes |
| Discharged or transferred to other types of health care institutions | Yes | Not listed |
| Critical care patients (99291, 99292) | Yes | Yes |
| Patient under 2 years old | Yes | Yes |
| Certain diagnoses that most often require greater than average resources, such as significant nursing time | Yes | Yes |
| Patient expired in the ED | Yes | Yes |
| Facilities whose level 4 and 5 billing does not deviate from the EDC Analyzer | Yes | Yes |
Exclusion criteria by list, nine in all
Shared by both policies
7 of 978%
Commercial onlydischarged or transferred
1 of 911%
Medicare Advantage onlyobservation
1 of 911%
SharedCommercialMedicare Advantage
Facts on the claim
Patient status, discharge status, age, critical care lines and the death indicator must be right before release.
The one difference favors MA
Observation is named with admission and surgery; commercial pairs admission with discharge or transfer.
One data pull, 30 adjusted claims, six steps
- 1
Pull adjusted level 4 and 5 claims by UHC product
- Commercial, Exchange and MA separately; the policies and exclusion lists differ
- 2
Check the reason-for-visit field
- Form locator 70 populated with a specific presenting-complaint code on every adjusted claim?
- 3
Reconcile diagnostic lines to orders
- All resulted labs, imaging, EKG and respiratory services on the claim as CPT lines?
- 4
Check complexity and external cause coding
- Managed comorbidities present; external cause codes on commercial claims?
- 5
Test the exclusions
- Any adjusted claim carrying a status that should have excluded it?
- 6
Split resubmit from appeal
- Incomplete claims go back corrected; complete claims go to reconsideration with the record
The first three steps explain most adjustments; the fix is registration, charge capture and coding, not appeals.
Four moves on UHC facility volume
Run the data pullOur emergency department billing services team can run it for you.
Tag each adjusted claim by causeMissing input, exclusion missed, or genuine disagreement.
Score level 4 and 5 claims before they leaveThe denial prediction engine tests them against payer rules.
Build the professional-side fileED facility E/M leveling defense and ED downcoding appeals.
Frequently asked questions
Which UHC policies govern ED facility E/M leveling in 2026?
Two: Reimbursement Policy 2026R6003A for commercial and Individual Exchange plans, and 2026R6007A for Medicare Advantage. Both were last changed on September 1, 2026, apply to UB-04 claims billed at level 4 (99284 or G0383) or level 5 (99285 or G0384), and use the Optum EDC Analyzer to determine the level UHC reimburses.
What data does the EDC Analyzer use?
Three factors from the claim: the ICD-10 reason-for-visit diagnosis, the intensity of diagnostic services measured by diagnostic CPT codes in four groups (lab, X-ray, EKG/RT/other, CT/MRI/ultrasound), and patient complexity from the principal and secondary diagnosis codes, plus external cause codes on the commercial policy.
How do the commercial and Medicare Advantage exclusion lists differ?
The Medicare Advantage list names observation status alongside inpatient admission and same-visit outpatient surgery; the commercial list instead names discharge or transfer to other health care institutions. Both exclude critical care, patients under 2, certain high-resource diagnoses and patients who expired in the ED.
What can a facility do when UHC adjusts a level 5 to a lower level?
UHC's Q&A gives two routes: resubmit with the diagnosis or procedure codes that were missing and support the billed level, or use the standard reconsideration and appeals process. On the commercial policy, UHC may also estimate payment for the adjusted code and invite a resubmitted claim on new charges.
- UnitedHealthcare Commercial and Individual Exchange Reimbursement Policy 2026R6003A, Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy, Facility (history entry September 1, 2026)
- UnitedHealthcare Medicare Advantage Reimbursement Policy 2026R6007A, Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy (history entry September 1, 2026)
Checked October 25, 2026. Rules and payer policies change; confirm against the source before relying on them.
Want your UHC level 4 and 5 adjustments tagged by cause?
We pull a quarter of adjusted claims by product, test each against the three inputs and the exclusions, and tell you which to resubmit, appeal or fix upstream.