Dec 29, 2020

Medicaid MCO's Improper Use of Triage Fee

By Brian M. Foley, Esq.

We discovered recently that at least one, and possibly more Medicaid Managed Care Organizations (“MCOs”) under contract with the State of New Jersey, have been misapplying Emergency Room Triage Fees to reduce payments for Emergency Room services.

In 2018, the State introduced the concept of the Emergency Room Triage Fee as part of original Medicaid. According to the policy, the Emergency Room Triage Fee of $140, will be paid in lieu of the normal fees for Emergency Room services, for certain low acuity care provided in the Emergency Room. (The policy was adopted by the State for original Medicaid only, but some of the Medicaid MCOs have also started using it. This should be addressed in contract language going forward.) The Emergency Room Triage Fee is to be paid only under very specific circumstances. According to the policy, claims that are submitted that meet all the following criteria will be paid the Emergency Room Triage Fee.

  • Revenue Code 45X is present on the claim,
  • Procedure code 99281, 99282, 99283, 99284, or 99285 are present on the claim, and
  • All of the first three diagnosis codes on the claim are on the current approved non-emergent diagnosis code list published on the NJMMIS website.

There are a number of exemptions to this policy, including pregnant women, children ages 6 or younger, seniors ages 65 or older, or inclusion of a certification of emergency form attachment.

We are seeing that at least one Medicaid MCO (and possibly others) may be inappropriately paying the Triage Fee in lieu of the normal Emergency Room rate, where the first three diagnosis codes contain one or more emergent codes. A list of diagnosis codes that constitute non-emergent codes is published by NJMMIS on its website.  Those non-emergent codes must appear in each of the first three diagnosis positions, for the payer to pay the Triage Fee.  Otherwise, they should pay the normal Emergency Room rates, as per the contract. Despite the presence of emergent codes in one or more of the first three positions, the payer is paying only the Triage Fee. In some cases, the payer paid the claim correctly, but then came back and recouped the original payment and issued payment of the Triage Fee of $140. We brought this issue to the attention of one of the Medicaid MCOs, who immediately ceased the practice and made full restitution to the hospital.

Hopefully, your hospital has not experienced this issue, but it is worth reviewing to make sure that the Medicaid MCOs are not paying inappropriately for your Emergency Room services. 

For more information or if you wish to discuss this issue, contact Brian M. Foley, Esq., at or (973)540-7326.



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