ER Prudent Layperson Facility Reviews

As of May 1, 2016 (dates of service), Magellan Complete Care will review emergency services claims to determine appropriate use of the emergency room and whether an emergency medical condition existed. As per the State of Florida Agency for Health Care Administration Statewide Medicaid Managed Care Contract language: 

Emergency Medical Condition — (a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention could result in any of the following: (1) serious jeopardy to the health of a patient, including a pregnant woman or fetus; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part. (b) With respect to a pregnant woman: (1) that there is inadequate time to effect safe transfer to another hospital prior to delivery; (2) that a transfer may pose a threat to the health and safety of the patient or fetus; (3) that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. (See s. 395.002, F.S.)

For services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, Magellan Complete Care will limit reimbursement to a triage fee (one revenue code at the outpatient per diem rate). There are two exceptions to this requirement:

  • The Primary Medical Physician referred the enrollee for treatment.
  • The enrollee called the Magellan Complete Care 24/7 Nurse Line and received prior authorization to go to the emergency room.

Magellan Complete Care has identified a list of diagnosis codes that qualify to autopay and would not be subject to review as these codes clearly demonstrate that an emergency condition existed. If the primary diagnosis codes match a diagnosis code on the autopay list, the claim will be paid following standard outpatient reimbursement guidelines. If the primary diagnosis code does not match a diagnosis code on the list, medical records will be reviewed by a Prudent Layperson to determine if the member presented with an emergency condition. 

At a minimum the facility will receive reimbursement for the triage fee to cover screening services. For facility charges billed on UB-04:

  • If the member did not present with an emergency condition, bill revenue code 451 for reimbursement of the triage fee (one revenue code at the outpatient facility per diem rate).