Claim Editing Changes for Emergency Department Services 

Posted 07/24/2023 Updated 02/28/2024

Important Update - The effective date for changes related to facility claims has been delayed and will be effective 04/01/2024. Refer to See New Effective Date for Claim Editing Changes for Facility Emergency Department Services 


Blue Cross and Blue Shield of Texas (BCBSTX) will enhance our claims editing and review process with Cotiviti for emergency department (ED) evaluation and management (E&M) for some of our commercial members. These editing enhancements for facility and professional claims will help ensure accurate billing and proper reimbursement.

What’s changing: when we review your claim, beginning Nov. 1, 2023, your reimbursement may be processed at a lower level of service if we cannot validate the level of E&M services billed. We will follow the American Medical Association guidelines for level of service and medical decision making.

What happens next: if you agree with the level of service reimbursed, no further action is needed. If you do not agree with the level of service reimbursed, you may submit additional medical records to support your claim.

Learn More: For more information on revisions to our ED claims editing process, please review the revised CPCP003 Emergency Department Evaluation and Management (E/M) Services – for Facility Services policy and our new CPCP042 Emergency Department Evaluation and Management (E/M) Services Coding – for Professional Services policy on our Clinical Payment and Coding Policy page.

Cotiviti, INC. is an independent company that provides medical claims administration for BCBSTX. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.