Facility emergency department evaluation and management (E&M) services reimbursement update

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) assesses the intensity and / or complexity of facility interventions and resources expended based on the services rendered during the facility Emergency Department (ED) Evaluation and Management (E&M) visit. Beginning December 15, 2025, if facility resources expended during the ED encounter do not align with E&M service billed, the claim service may be subject to denial or reimbursed based on the appropriate E&M level.

Facilities may request a post-service reconsideration through the Facility Emergency Department Reconsideration Process in Blue e^℠.

Please see the related policy notification for more information.

This change will apply to Commercial, Inter-Plan Program (IPP) Host and Medicare Advantage (MA). This will not apply to IPP Home or Federal Employee Program^® (FEP).