Anthem has made several changes and clarifications to its emergency department (ED) use policy since it was introduced, and the health plan says more changes may be made. As of mid-March, Anthem said it will not deny an ED claim based on the prudent layperson standard if it determines that any one or more of the following conditions apply:
● A provider, including an ambulance driver, directed the patient to the ED.
● The patient was under the age of 15.
● The patient’s home address is more than 15 miles from an urgent care center.
● The visit occurred between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday.
● The patient is traveling out of state.
● The patient received any kind of surgery.
● The patient received IV fluids or IV medications.
● The patient received an MRI or CT scan.
● The visit was billed as urgent care.
● The ED visit is associated with an outpatient or inpatient admission.
See related article: Limiting Emergency Department Denials and Surprise Bills