The Health Plan follows the Bureau for Medical Services’ (BMS) guidelines pertaining to reimbursement for emergency room services rendered to Medicaid members.
Medicaid covers five levels of emergency room services. There are five CPT procedure codes available for billing emergency room services.
The enhanced reimbursement is an all-inclusive fee, which is considered to include the following items:
- Use of emergency room
- Routine supplies (such as sterile dressings)
- Minor supplies (bandages, slings, finger braces, etc.)
- Pharmacy charges
- Suture, catheter, and other trays
- IV fluids and supplies
- Routine EKG monitoring
- Oxygen administration and O2 saturation monitoring
Diagnostic procedures including lab and radiology may be billed separately and in addition to the emergency room services.
Hospital guidelines may be viewed in their entirety in Chapter 510 of BMS’ Provider Manual located here.
Billing Requirements for Outpatient Services Performed in Hospitals
Effective January 1, 2020, CPT/HCPCs codes are required to be submitted with the applicable revenue code for all outpatient services provided to Medicaid members in an acute or critical access hospital setting. Claims billed with revenue codes submitted without the corresponding procedure code(s) will be denied.
Attention: Non-Par Providers
Unless it has been prior authorized, all non-participating providers providing services to West Virginia Medicaid members will be reimbursed at 80 percent of the current West Virginia Medicaid fee schedule. Failure to obtain prior authorization for any service performed by an out-of-network non-patient facing provider will result in claim denial.