UB-04 only
Claim type
- Facility claims on the UB-04 or its electronic equivalent
- Professional CMS-1500 claims fall under separate E/M policies [1]
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White paper · ED facility E/M leveling
ED facility E/M leveling defense: beating the EDC Analyzer and Anthem G-19002 in 2027
Short answer: UHC re-levels facility 99284 and 99285 claims with the Optum EDC Analyzer; Anthem classifies resource intensity from the claim and can recoup. Both decide from claim data before anyone reads the chart. Treat the UB-04 as the first appeal.
UHC 2026R6003A · 2026R6007A
Anthem G-19002 · deny, adjust, recoup
99284 · 99285 · G0383 · G0384
45 CFR 149.110(b)(4) · not solely by diagnosis
Edition
White paper · 2027
Focus
ED facility E/M
Payers
UHC · Anthem
Codes
99284 · 99285 · G0383 · G0384
Framework
45 CFR 149.110(b)(4)
Length
15 min read
3inputs
Reason for visit, diagnostic intensity and complexity diagnoses drive the Calculated Visit Level [1]
Sep 12026
Anniversary review date on both UHC ED facility E/M policies [1]
3actions
Deny, adjust or recoup: what Anthem G-19002 reserves when a billed level exceeds its classification [3]
$922,524
OIG-found Medicare overpayments on 9,749 ED visit codes with a non-ED place of service [8]
Two payers re-level by algorithm, not by chart review
Neither policy reads the physician's note first. Both read the UB-04: revenue codes, CPT and HCPCS lines, reason-for-visit, principal and secondary diagnoses. The claim has to carry what the chart says, line by line.
99284 and 99285
Codes in scope
- Plus Type B ED equivalents G0383 and G0384
- Critical care 99291 and 99292 are listed as exclusions [1]
Every ED
Scope
- UHC's own Q&A: the policy applies to all emergency departments, facility-based, freestanding or otherwise [1]
Takeaway
An algorithm that re-levels from claim data can only be answered with claim data. Treat the UB-04 as the first appeal.
Three factors from the claim, one calculated level
Input 1 · presenting problemsReason-for-visit diagnosisICD-10 RFV code, form locator 70
Input 2 · diagnostic servicesDiagnostic CPT lines, four groupsLab; X-ray; EKG, RT and other diagnostic; CT, MRI and ultrasound
Input 3 · complexity and co-morbidityPrincipal and secondary diagnosesCommercial adds external cause of injury codes
Optum EDC AnalyzerCalculated Visit LevelCompared with the billed level 4 or 5
Both policiesAdjust"May experience adjustments" to the lower code
Both policiesDeny"May receive a denial for the code level submitted"
Commercial onlyEstimateEstimate reimbursement from historical claims experience, then adjudicate a resubmitted claim on the new charges [1]
Nursing time, medication passes, reassessments, restraints and length of stay are not inputs unless a CPT, HCPCS or diagnosis code represents them. The charge description master decides how much real work the analyzer counts.
| Factor | What the policy says it reads | Commercial and Exchange (2026R6003A) | Medicare Advantage (2026R6007A) |
|---|---|---|---|
| Presenting problems | The ICD-10 reason for visit (RFV) diagnosis | RFV diagnosis | RFV diagnosis |
| Diagnostic services performed | Intensity of the diagnostic workup measured by diagnostic CPT codes: Lab, X-ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound | Same four groups | Same four groups |
| Patient complexity and co-morbidity | Complicating conditions or circumstances defined by ICD-10 codes | Principal, secondary and external cause of injury diagnosis codes | Principal and secondary diagnosis codes [2] |
Nine criteria across three policies, side by side
UHC's criteria "may exclude" a claim [1] [2]; Anthem's list is shorter with the same spine [3].
| Exclusion | UHC commercial 2026R6003A | UHC Medicare Advantage 2026R6007A | Anthem G-19002 (CA Medi-Cal) |
|---|---|---|---|
| Admitted to inpatient | Yes | Yes | Yes (admitted or transferred) |
| Placed in observation | Not listed | Yes | Yes |
| Outpatient surgery during the same ED visit | Yes | Yes | Yes |
| Discharged or transferred to another institution | Yes | Not listed | Transferred to another facility |
| Critical care (99291, 99292) | Yes | Yes | Yes |
| Patient under 2 years old | Yes | Yes | Not listed |
| Certain diagnoses that most often need greater than average resources | Yes | Yes | Not listed |
| Patient expired in the ED | Yes | Yes | Yes |
| Facility's level 4 and 5 billing does not deviate from the EDC Analyzer | Yes | Yes | Not applicable |
How many of the three policies list each exclusion
Disposition is a defense in its own right; the critical care exclusion is only as good as the 99291 line; the non-deviating row is a measurable target.
Admitted to inpatient
3 of 3100%
Outpatient surgery, same visit
3 of 3100%
Critical care 99291, 99292
3 of 3100%
Patient expired in the ED
3 of 3100%
Observation
2 of 367%
Discharged or transferred
2 of 367%
Under 2 years old
2 of 367%
High-resource diagnoses
2 of 367%
Non-deviating facility
2 of 367%
All threeTwo of three
Takeaway
Disposition, age, critical care and death are facts on the claim. Make sure they are the right facts before you argue about the level.
A resource-intensity model with recoupment rights
Anthem classifies "the intensity and/or complexity of resources or interventions a facility uses to furnish all services indicated on the claim": staff and their work, building, equipment and supplies, plus presenting problem, member age, acuity and diagnostic services [3]. Copy reviewed: California Medi-Cal, approved April 24, 2020, re-approved January 16, 2024; pull your own state's first.
| Dimension | UHC EDC Analyzer | Anthem G-19002 |
|---|---|---|
| Decision engine | Named third-party algorithm (Optum EDC Analyzer) producing a Calculated Visit Level | Anthem's own classification of resource and intervention intensity |
| Inputs named | RFV diagnosis, diagnostic CPT groups, principal and secondary (and external cause) diagnoses | All services on the claim, presenting problem, member age, acuity, diagnostic services |
| Front-end actions | Adjust to the calculated level or deny; commercial may estimate payment then invite resubmission | Deny and request resubmission or records; adjust to the lower level |
| Back-end action | Standard reconsideration and appeal | Explicit right to recover or recoup prior payments above the supported level |
| Professional services | Separate professional E/M policy | Professional provider services are not counted as facility interventions or resources |
| Reference set | CMS facility coding principles, CPT and HCPCS descriptors | 42 CFR 422.113, EMTALA, ACEP ED Facility Level Coding Guidelines, Optum EncoderPro |
A UHC adjustment shows on the remit within weeks; an Anthem recovery can arrive long after the account closed. Keep the evidence file for the full contractual look-back.
Payer ED leveling rules in force for 2026 and 2027, professional and facility
Independent ED groups face parallel rules on 99284 and 99285. Diagnosis codes drive the first decision; records drive the reversal.
| Payer and policy | Claim type | Trigger | Default action | What restores the level |
|---|---|---|---|---|
| UHC 2026R6003A, 2026R6007A [1] | Facility UB-04 | Calculated Visit Level below billed level 4 or 5 | Adjust or deny | Complete diagnosis and diagnostic coding; reconsideration or appeal |
| Anthem G-19002 [3] | Facility UB-04 | Billed level above resource-intensity classification | Deny, adjust or recoup | Resubmission at supported level or documentation |
| Cigna R36 (Feb 13, 2026) [5] | Professional CMS-1500 | 99284 or 99285 with a single non-complex diagnosis | Paid as 99283 | Records showing MDM complexity; cloned notes rejected |
| Aetna (Jul 8, 2024) [6] | Professional and facility | Level 4 or 5 not supported by claim details | Payment adjusted | Review and appeal |
| Florida Blue 26-088 (Jun 1, 2026) [7] | Professional CMS-1500 | 99285 with a low-acuity non-emergent diagnosis; excludes under 2, hospital-billed ED E/M, Medicare-primary | Repriced to 99284 | Appeal with records |
| UHC 2026R5007A (Apr 1, 2026) [10] | Professional CMS-1500 | MDM does not support the billed level; applies in a CPT-defined ED including hospital-owned freestanding EDs | Adjusted or denied | MDM documented in the note |
Cheap fix
OIG found $922,524 in Medicare overpayments on 9,749 ED visit codes billed with a non-ED place of service [8]. ED codes 99281 to 99285 belong with POS 23; one scrubber rule removes the audit category.
Built around the claim, with the note as evidence
- 1
Charge master
Map the facility level criteria to charge lines
- Each intervention in the leveling guideline names its CPT, HCPCS or revenue code
- No line, no credit
- 2
Registration and triage
Make the reason for visit a required field
- Form locator 70 captured as coded data, not free text
- 3
Charge capture
Code every diagnostic service the claim carried
- Reconcile orders to charges daily; a resulted CT or second troponin is never a missing line
- 4
HIM coding
Capture complexity diagnoses and external cause codes
- Coder prompt for chronic conditions the ED actively managed; external cause codes on the commercial book
- 5
Patient access and HIM
Lock disposition and patient status before release
- Admit, observation, transfer and expired are exclusions in their own right
- 6
Nursing and HIM
Bill critical care minutes the facility actually delivered
- Facility 99291 removes the claim from scope under all three policies
- 7
Submit gate
Run a pre-bill level check on every level 4 and 5
- Score against the three inputs; our denial prediction engine already scores every line against more than 80 CARC patterns
- 8
Appeals
Keep a claim-level evidence file
- UB-04, note, nursing record and MAR together for every adjusted level 4 and 5
| Pre-bill check | Protects against | Owner | Frequency |
|---|---|---|---|
| RFV diagnosis present and specific | Presenting-problem input scored as low acuity | Registration and triage | Every encounter |
| Orders to charges reconciliation | Diagnostic workup input understated | ED charge capture | Daily |
| Secondary and external cause coding | Complexity input understated | HIM coding | Every level 4 and 5 |
| Patient status and discharge status | Loss of an admit, observation, transfer or expired exclusion | Patient access and HIM | Pre-bill |
| Critical care minutes billed | Loss of the critical care exclusion | Nursing and HIM | Pre-bill |
| POS 23 on professional claims | Medicare non-ED place of service overpayment findings | Professional billing | Scrubber rule |
Takeaway
A level 5 is not a documentation outcome. It is a claim outcome: the RFV, the diagnostics, the complexity codes and the disposition all have to be there.
The prudent layperson anchor, then the record
For plan years from January 1, 2022, 45 CFR 149.110 covers emergency services without prior authorization, in or out of network, and "without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes"; the condition is the prudent layperson's view of presenting symptoms, including severe pain, mental health and substance use disorders [4]. It sets no payment level; it bars judging chest pain by a reflux discharge diagnosis. Full letter: ED downcoding appeals.
| Element | Why it matters | Where it lives |
|---|---|---|
| Triage note with chief complaint, vitals and acuity | Shows the presenting symptoms a prudent layperson would have judged | Nursing record |
| Orders and results timeline | Shows the diagnostic intensity the facility actually used | Order log, lab and imaging results |
| Medication administration record | Shows interventions, routes and reassessments that drive facility intensity | MAR |
| Nursing reassessments and monitoring | Facility resources the claim cannot show on its own | Nursing flowsheet |
| Physician MDM and disposition | Ties the facility level to the clinical decision and the disposition exclusion | Physician note |
| Itemized UB-04 with all diagnosis codes | Proves the analyzer inputs were present at first adjudication | Billing system |
| Citation to 45 CFR 149.110(b)(4) and the plan's own exclusions | Frames the request as a coverage rule, not a coding opinion | Appeal template |
The letter
- 1
Open with the coverage rule
- 45 CFR 149.110(b)(4) and the plan's own exclusion list; presenting symptoms, not discharge diagnosis, define the emergency
- 2
State the presenting picture
- Chief complaint, triage acuity, vitals, time of arrival, in two or three lines
- 3
Show the resources used
- Orders timeline, results, medications, nursing reassessments, each tied to a line on the itemized claim
- 4
Ask for one thing
- Restoration of the billed level and payment of the difference, with account, claim number and remit date
Which route
Resubmit
The original claim was missing a diagnosis code, a diagnostic line or the correct patient status. Fix the claim and send it again; UHC's Q&A invites this route [1].
Appeal
The claim was complete and the payer still re-leveled it. Use the reconsideration process with the evidence file and the coverage citation.
Never both
A corrected claim and an appeal on the same account create duplicate-claim denials and muddy the timeline. Log the route you chose.
Five numbers a month
| Measure | Definition | Why it moves the P&L |
|---|---|---|
| Level 4 and 5 adjustment rate by payer | Adjusted or denied level 4 and 5 facility claims divided by level 4 and 5 claims billed, per payer | The direct cost of the policies; the UHC exclusion for non-deviating facilities is reached by driving this down |
| Share of adjustments with a missing input | Adjusted claims where the RFV, a diagnostic line or a complexity diagnosis was absent at first submission | Claim-build defects that resubmission fixes without an appeal; the measure most programs skip, and the one that pays fastest |
| Exclusion capture rate | Claims eligible for an exclusion (admit, observation, transfer, critical care, expired, under 2) that carried it correctly | Lost exclusions are the cheapest leveling losses to prevent |
| Appeal overturn rate and days to decision | Appealed level adjustments restored, and median days from remit to decision | Whether the evidence file works and how long cash waits |
| Net level mix drift | Month-over-month change in the paid level distribution versus the billed distribution | Early warning that a payer changed its model or a department changed its capture |
Find the defect you actually have: a new ER group's first four weeks
Baseline: our ER group first-30-days case study.
Claims confirmed received by payer
93.3%within four weeks
Remittance denials from provider enrollment45 of 46
97.8%not coding
Claim exceptions that were coding errors0 of 79
0%0 of 79
0%25%50%75%100%
HealthyEnrollmentCoding
Measurement first, claim build second, appeals third
Days 1 to 30Measure
Hospital ED, facility
- Pull 12 months of level 4 and 5 adjustments by payer
- Tag each for missing inputs versus disagreement
- Confirm patient status accuracy
- Pull 99284 and 99285 downcodes by payer; map to R36, 26-088, 2026R5007A and Aetna rules
- Confirm POS 23 on every ED claim
Days 31 to 60Build the claim
Hospital ED, facility
- Make RFV mandatory; reconcile orders to charges daily
- Add secondary and external cause prompts
- Build the pre-bill level check
- MDM prompt per ED level in the note template; stop cloned text
- Score 99284 and 99285 against payer diagnosis lists before release
Days 61 to 90Appeal and measure
Hospital ED, facility
- Stand up the evidence file and the appeal template citing 149.110
- Start the five-number scorecard
- Review Anthem recoupments for look-back exposure
- Appeal template with triage vitals and MDM
- Track overturn rate and days to decision; report level mix drift monthly
Five moves before the next remit
Pull adjusted level 4 and 5 claims by payerBy product; tag missing input versus disagreement.
Check the three inputs on eachRFV, diagnostic CPT lines, complexity and external cause codes.
Test the exclusionsAdmit, observation, transfer, critical care, under 2, expired.
Add the POS 23 scrubber ruleOne rule removes the OIG audit category on professional claims.
Get a second pair of eyes on the first 30 daysOur emergency department billing services team runs this baseline. Detail: UHC EDC Analyzer, Anthem G-19002, what ER groups should demand.
Frequently asked questions
What is the EDC Analyzer and which claims does it apply to?
The Emergency Department Claim Analyzer is an Optum algorithm that UnitedHealthcare uses to determine the ED E/M level it will reimburse on certain facility claims billed on the UB-04 at level 4 (99284 or G0383) or level 5 (99285 or G0384). It reads the reason-for-visit diagnosis, the intensity of diagnostic services, and patient complexity shown by diagnosis codes.
Which ED facility claims are excluded from UHC leveling adjustments?
UHC lists criteria that may exclude a claim: the patient was admitted to inpatient (the Medicare Advantage policy adds observation), had outpatient surgery during the ED visit, was discharged or transferred to another institution, received critical care (99291 or 99292), was under 2 years old, had certain diagnoses that typically need greater than average resources, or expired in the ED.
How does Anthem's ED leveling policy G-19002 differ from UHC's?
Anthem does not name an external tool. Policy G-19002 says Anthem classifies the intensity and complexity of the resources and interventions the facility used, based on all services on the claim, and if the billed level is higher than that classification it may deny and request resubmission or documentation, adjust payment to the lower level, or recoup prior payments.
Can a plan downcode an ED visit based only on the discharge diagnosis?
For plan years beginning on or after January 1, 2022, 45 CFR 149.110(b)(4) requires plans to cover emergency services without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes, and defines the condition from the presenting symptoms as a prudent layperson would judge them. The rule does not set a payment level, but it is the anchor for an appeal when a re-level rests on the final diagnosis alone.
Should we resubmit or appeal an adjusted level 5?
Resubmit when the original claim was missing diagnosis codes or diagnostic lines that support the level; UHC's own Q&A invites that. Appeal through the payer's reconsideration process when the claim was complete and the algorithm still disagreed, and build the appeal from the triage note, orders timeline, medication record, nursing reassessments, physician MDM and the itemized claim.
- UnitedHealthcare Commercial and Individual Exchange Reimbursement Policy 2026R6003A, Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy, Facility (anniversary review September 1, 2026)
- UnitedHealthcare Medicare Advantage Reimbursement Policy 2026R6007A, Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy (version change September 1, 2026)
- Anthem Blue Cross (California Medi-Cal Managed Care) Reimbursement Policy G-19002, Emergency Department Leveling of Evaluation and Management Services (effective January 16, 2024)
- 45 CFR 149.110, Preventing surprise medical bills for emergency services (eCFR)
- Cigna Reimbursement Policy R36, Emergency Room Services (updated February 13, 2026)
- Aetna OfficeLink Updates, April 2024: review of level 4 and 5 ER claims from July 8, 2024
- Florida Blue Payment Policy 26-088, Emergency Department Services (effective June 1, 2026)
- HHS-OIG report A-07-23-05139 (March 9, 2026): ED procedure codes billed with non-ED sites of service
- CMS fact sheet: Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F)
- UnitedHealthcare Commercial and Individual Exchange Reimbursement Policy 2026R5007A, Evaluation and Management Services, Professional (reviewed April 1, 2026)
Checked October 25, 2026. Rules and payer policies change; confirm against the source before relying on them.
ServiceEmergency department billing services
InsightUHC EDC Analyzer policy, 2026 read
InsightAnthem ED leveling policy G-19002 audit
BlogED downcoding appeals and the prudent layperson standard
NewsletterCritical care 99291 documentation that pays
TechnologyPre-submit denial prediction
ServiceEmergency room billing services
Want your level 4 and 5 exposure measured?
We pull twelve months of adjusted ED levels by payer, tag each for missing inputs versus disagreement, and hand you the pre-bill checks and appeal file that fit your department.