Harvard Pilgrim Updates Emergency Care Payment Policy

March 2019 ~

Harvard Pilgrim has issued updates to its current payment policy for emergency services.

According to the updated policy guidelines, Harvard Pilgrim will reimburse emergency department services based on the member’s prudent layperson judgment to seek emergency care. Payment is based on member benefits and eligibility, medical necessity review, where applicable, and provider contractual agreement. Payment for covered services rendered by contracted providers will be reimbursed at the lesser of charges or the contracted rate.

The updated payment policy for emergency services, applicable to the products of Harvard Pilgrim Health Care and its affiliates for services performed by contracted providers, can be seen below.

Harvard Pilgrim Will Reimburse


Emergency department (ER) care is reimbursed at a contracted rate, including:

  • Room and facility services directly related to the services provided as part of the emergency department care including incidentals (i.e., pharmacy and supplies billed under revenue code 25X & 27X).
  • Procedures performed in the emergency department setting including surgical procedures, physical therapy, and treatment room.

Ancillaries are reimbursed separately from ER contracted rate. (Ancillary services are defined as services such as laboratory, pathology, radiology, etc.).

Follow-Up Care

If the attending ER physician recommends follow-up care after emergency department treatment, it must be approved or provided by the member’s PCP to be considered for reimbursement. The ER is not the appropriate location for non-emergency follow-up care.

Emergency Department Services Resulting in Outpatient Surgery

  • Surgical procedures performed exclusively in the emergency department setting will not be reimbursed separately; the reimbursement for these services is included in the emergency department contracted rate.
  • Emergency department services provided in conjunction with surgical procedures performed outside of the ER setting (i.e., operating room, ambulatory surgery, clinic, treatment room) will not be reimbursed separately; these services are reimbursed according to the facilities all-inclusive surgical contracted rate.

Emergency Department Services Preceding an Observation Stay

When emergency room services precede an observation stay, the entire emergency episode is included in the observation reimbursement for inclusive payment according to the contracted observation rate.

Emergency Department Services Resulting in an Inpatient Stay

Emergency department services rendered immediately prior to a related inpatient admission are included in the contracted inpatient payment rate and terms. The hospital must notify Harvard Pilgrim of the inpatient admission within 48 hours or next business day.

Harvard Pilgrim Will Not Reimburse


  • Routine care services, including but not limited to physical exams, diagnostic tests, or preventive procedures, provided in the ER.
  • Care a member could have foreseen before leaving the service area.

Member Cost-Sharing

Services subject to applicable member out-of-pocket cost (e.g., copayment, coinsurance, deductible). Emergency department copayment is waived when:

  • Harvard Pilgrim is the secondary payer (COB, MVA, WC).
  • Emergency care results in an observation stay or an inpatient admission.

Provider Billing Guidelines and Documentation


Professional Evaluation & Management services in a Facility-Based Urgent Care Location

  • Submit services on a CMS-1500 claim form or electronic 837P, version 5010.
  • Place of Service code 23: Emergency Room-Hospital is required.

Emergency Department Services Resulting in an Inpatient Stay

Bill using revenue codes representing the emergency care and inpatient services rendered.

Emergency Department Services Resulting In Surgical Day/Ambulatory Surgery

Bill the appropriate revenue code (045X) and CPT® codes representing the services rendered in the emergency department and the appropriate revenue code series 036X and the CPT® code(s) representing the services rendered (i.e., CPT® code range 10021–69990) for the surgical day care procedure.

Other Information

Bill motor vehicle accidents or workers’ compensation cases using diagnosis codes indicating an accident, fire, etc. If applicable, enter other insurance information in Form Locator 50 of the paper UB-04.

For completing the other insurance, other subscriber, and other coordination of benefits information for electronic claims, refer to the 837 institutional implementation guide.

Providers must follow all state or federal rules when prescribing medications, including any mandate review through a Prescription Monitoring Program (PMP). Harvard Pilgrim Health Care may review claims for medical appropriateness where it has concerns that the PMP is not being used or the prescriptions given are not medically appropriate.

See the policy update in its full text, here.

CPT® is a registered trademark of the American Medical Association.



Source(s): Harvard Pilgrim;