Superior Health plan Leveling of Care Policy

Superior HealthPlan is implementing a new policy on Leveling of Care for office based Evaluation and Management Over-coding (CC.PP.066)

Nurse adjusting IV drip to ensure proper care level

What Superior Leveling of Care Means

Superior will implement an automated pre-payment claims review process to assess and standardize the correct level of evaluation and management (E&M) service effective February 1, 2026.

The coding algorithm will analyze each diagnosis code billed on the claim header, along with historical claims and other claim data, like testing, to verify if the service level is suitable.

When multiple diagnosis codes are billed, the algorithm will assess each code and additional claims information to assign a maximum service level to each diagnosis.

For instance, if three diagnosis codes are billed on the claim header, with two assigned a maximum service level of three (99213) and one assigned a maximum level of four (99214), then a level four E&M code is permitted.

Coding validation will encompass, but is not limited to, the current claim details for the member, member claim history, and information from the associated facility claim that may indicate resources used during the ED visit (such as labs, radiology, pharmaceuticals provided, and radiology services) and the specialty provider's interpretation of diagnostic services performed.

Therefore, if the reported E&M service is identified as a higher-level procedure code than expected, the provider reimbursement will be adjusted to reflect the appropriate level of ED E&M service.

The minimum level of service to which an E&M code may be reduced is level three (i.e., 99213) for E&M services with five levels, and level two for ophthalmology E&M services (i.e., 92002 or 92012).

Each E&M category (such as new visits, established visits, new ophthalmology visits, established ophthalmology visits, and office consultations) has its own assigned values. E&M services will not be denied due to this policy, but they will be reviewed and may be reduced based on the level of service performed.

For more information refer to Superior's policy here:

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