Emergency Medicaid Services Billing Manual (2024)

• General Billing Information
• General Eligibility Information
• Covered Services
  • Emergency Medical Condition
  • Labor and Delivery Services
  • Dialysis Services
• Non-Covered Services
• Service Location
• Reproductive Health Care Program
• Billing Guidance
• Timely Filing
• Compliance
• Emergency Medicaid Services Revision Log

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Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.

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General Eligibility Information

Effective August 8, 2021, a physician statement certifying the presence of an emergency medical condition is not needed to apply for Emergency Medicaid Services (EMS).

Effective July 1, 2022, individuals deemed eligible for EMS will remain enrolled for a 12-month period until their renewal, unless there is a qualifying life event that changes their eligibility.

See HCPF Policy Memo 22-006.

Members can learn more about applying for EMS on the Health First Colorado website.

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Covered Services

The Emergency Medicaid Services (EMS) benefit plan covers services necessary to treat an emergency medical condition as defined below, family planning services and family planning-related services for people who qualify.

Emergency Medical Condition

Emergency medical condition is defined as, “a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

1. Placing the patient’s health in serious jeopardy,
2. Serious impairment to bodily function, or
3. Serious dysfunction of any bodily organ or part.”

See 42 U.S.C. § 1396b(v)(3); Colorado Revised Statutes § 24-76.5-102(1); and 10 CCR 2505-10, § 8.100.3.G.1.g.viii.

Stabilization is not a consideration in determination of EMS coverage. Emergency Medical Conditions may persist after a member is stabilized.

EMS is not limited by diagnosis or condition except as noted in the Non-Covered Services Section.

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Labor and Delivery Services

Labor and delivery services are included in the definition of services necessary to treat an emergency medical condition. This includes vagin*l or cesarean delivery. Postpartum and prenatal services are not covered; therefore, global billing codes cannot be used on claims for EMS members. Claims must be submitted per EMS billing guidance to be covered.

Effective July 1, 2022, Emergency Medicaid members are eligible for reproductive healthcare, including contraceptives and sterilization procedures. For sterilization services, documentation following federal and state compliance guidelines for sterilization consent, which includes timely completion and member signature of the Consent to Sterilization - MED 178 Form (30 days prior to sterilization procedure), are required and must be attached with claims. When submitting labor and delivery claims for EMS recipients, include all services provided during this episode of care on the claim.

Prior to July 1, 2022, if a sterilization was performed in conjunction with the labor and delivery for a for an Emergency Medicaid member, the coding and charges for the sterilization would be omitted from the claim and only the codes and charges for the delivery could be billed.

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Dialysis Services

Effective February 1, 2019, End-Stage Renal Disease (ESRD) is considered an emergency medical condition for purposes of coverage under EMS. EMS members can receive care and services related to the treatment of ESRD, including but not limited to scheduled dialysis at a free-standing facility, home dialysis, and vascular access procedures.

Refer to the Dialysis Billing Manual for information.

See the July 2019 Provider Bulletin.

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Non-Covered Services

The following services are not covered by EMS:

Organ transplants, care and services related to an organ transplant procedure. Routine prenatal or post-partum care, follow-up care, long-term care. Outpatient pharmacy, defined as pharmacy services billed through the Pharmacy Benefit Management System. Any care not certified as an emergency.

See 42 U.S.C. § 1396b(v)(2)(C)

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Service Location

When an emergency medical condition is present, members can receive treatment at any facility type.

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Reproductive Health Care Program

Effective July 1, 2022, EMS members are eligible for the Reproductive Health Care Program (RHCP), which covers family planning and family planning-related services for eligible individuals. Individuals are eligible for RHCP regardless of age or gender. Covered services should occur in a family planning setting and do not need to be an emergency. If family planning services are medically necessary to treat an emergency medical condition for EMS members, the claim must have the appropriate emergency indicator on claims forms. Billing guidance for the RHCP differs from EMS, please refer to the Family Planning Benefit Expansion for Special Populations Billing Manual for information about billing guidelines and covered services. Provider questions can be sent to hcpf_maternalchildhealth@state.co.us.

Please note that the Emergency Medicaid/Reproductive Health Care Benefit Plan covers members for federally and state-funded EMS-covered emergency services, and state-funded RHCP covered family planning and related services; members do not need to reapply or enroll in a separate benefit plan to receive coverage for these services. Additional provider and member resources can be found on the Reproductive and Maternal Health Programs and Resources web page.

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Billing Guidance

Per the Department's regulations at 10 CCR 2505-10, § 8.100.3.G.1.g.viii, a provider must certify the presence of an emergency medical condition when services are provided. Claims submitted for EMS members must have the appropriate emergency indicator on claim forms. The provider must use the following claim form fields to certify that the claimed services relate to emergency medical conditions:

Billing for Services Covered by the EMS Benefit Plan

Concerns regarding denied claims should be directed to the Department’s fiscal agent, Gainwell Technologies 1-844-235-2387.

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Timely Filing

<>For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

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Compliance

The Department conducts routine reviews of Medicaid covered services to ensure that providers are complying with both federal and state statutes, rules, and guidance. These reviews can take many forms and include, but are not limited to, prospective, concurrent, or post-payment reviews of claims data, medical records, and licensing information. If these reviews reveal noncompliance, depending on the issue, the Department may recover identified overpayments, request a written response on how the provider will come into compliance, and/or provide education to the provider.

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Emergency Medicaid Services Revision Log

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