California emergency department billing services
Professional ER billing for emergency medicine groups in California: MDM-based 99281-99285 levels, critical care time, modifier 25, payer enrollment and No Surprises Act claims, built on the California payer rules verified below.
What changes an ER claim in California.
Every California rule on file, each linked to its primary source: state surprise-billing law, Medicaid ER policy, Medicaid managed care, the Blue plan and the Medicare contractor.
| Rule type | Date | What it says | Source |
|---|---|---|---|
| State surprise-billing law | Jan 2009 | Knox-Keene (DMHC) plans must pay ER providers until the patient is stabilized, with no prior auth; payment may be denied only if services were never performed, or for a screening exam when the enrollee reasonably should have known no emergency existed (H&S 1371.4). | Source |
| Medicaid managed care | Mar 2019 | Health Net California (all products, including Medi-Cal) policy HNCA.PP.053: when a physician bills 99284 or 99285 with a lower-severity diagnosis, the claim is pended and the provider gets written notice that manual review is required before payment. Policy last reviewed 03/01/2019. | Source |
| Medicare contractor | Jul 2026 | Medicare Part B professional ER claims go to Noridian Healthcare Solutions, A/B MAC Jurisdiction E (JE). | Source |
How we bill California ER visits.
The same four-step workflow we run for emergency medicine and hospitalist groups billing from their hospital system.
Hospital feed and registration
Demographics, insurance and the attending physician arrive from the hospital system daily. Gaps go back to registration as clarification requests, not guesses.
MDM levels and critical care minutes
ED visits 99281-99285 are coded on medical decision making only. Critical care is 99291 for 30 to 74 minutes and 99292 from 104 total minutes, on documented time.
Modifier 25 and enrollment check
A separately identifiable E/M on the day of a procedure carries modifier 25 with its own documentation. The rendering physician is checked against the payer roster before release.
Submission, remit and NSA/IDR
Professional claims go out with place of service 23. Out-of-network ER claims follow the No Surprises Act: in-network cost share only, open negotiation, then federal IDR.
FAQ: ER billing in California.
Does California have a state surprise billing law for ER care?
Knox-Keene (DMHC) plans must pay ER providers until the patient is stabilized, with no prior auth; payment may be denied only if services were never performed, or for a screening exam when the enrollee reasonably should have known no emergency existed (H&S 1371.4).
How do California Medicaid managed care plans handle ER claims?
Health Net California (all products, including Medi-Cal) policy HNCA.PP.053: when a physician bills 99284 or 99285 with a lower-severity diagnosis, the claim is pended and the provider gets written notice that manual review is required before payment. Policy last reviewed 03/01/2019.
Which Medicare contractor processes California ER professional claims?
Medicare Part B professional ER claims go to Noridian Healthcare Solutions, A/B MAC Jurisdiction E (JE).
How are emergency department visit levels chosen in California?
By medical decision making only. CMS states that for emergency department visits practitioners use MDM, not time, to select 99281-99285, so the note must carry the problems addressed, the data reviewed and the risk of management.
Can an out-of-network ER physician in California bill the patient for the balance?
Not for covered emergency services. Under the federal No Surprises Act, out-of-network providers of emergency services cannot bill the patient more than in-network cost sharing, and the notice-and-consent exception does not apply to emergency medicine.
Nearby ER billing state guides.
Neighbouring state pages with their own verified ER payer rules.