Effective June 1, 2026, we will begin applying national CPT billing guidelines for the appropriate coding of physician Evaluation and Management (E&M) code levels.

Date: 04/29/26

Meridian and its family of plans—Meridian Medicaid Plan, Wellcare Meridian Dual Align (HMO D-SNP), and YouthCare, are committed to continuously improving claims review and payment processes. Effective June 1, 2026, we will begin applying national CPT billing guidelines for the appropriate coding of physician Evaluation and Management (E&M) code levels. This applies to Meridian Medicaid Plan, Wellcare By Meridian D-SNP, and YouthCare claims.

The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely to be incorrectly coded, resulting in improper payments to providers. The OIG recommended that payers continue to help to educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed by high-coding practitioners.

Overview of the E&M Program

Evaluates and reviews only high-level E&M services based upon diagnostic information that appears on the claim. This includes, but is not limited to, current claim information, member claim history and information from other claims for the same date of service such as diagnostic services. Applies the relevant E&M policy and re-coding of the claim line to the corrected E&M level of service
Allows reimbursement at the highest E&M service code level for which the criteria is satisfied based on our comparative peer risk adjustment process
Applies to E&M service for in-office and emergency department settings

Providers should report E&M services in accordance with American Medical Association’s (AMA) CPT® Manual and the Centers for Medicare and Medicaid Services (CMS') guidelines for billing E&M service codes, Documentation Guidelines for Evaluation and Management. The proper reporting of E&M services enables us to precisely apply reimbursement-coding guidelines and ensure that an accurate record of patient care history is maintained.

Determinations should be made with reference to accepted standards of medical practice and the medical circumstances of the individual case.

Find policy details on Meridian’s website on the Clinical and Payment Policies web page, and on YouthCare’s website at Clinical and Payment Policies.

Policy Numbers	CC.PP.066 & CC.PP.076
Policy Names	Leveling of Care Office Based EM Over-coding & Leveling of Care Emergency Department EM Over-coding
Lines of Business Impacted	Meridian Medicaid Plan, YouthCare, and Wellcare By Meridian D-SNP

Claims identified as over-coded during the review will be processed as follows

The over-coded CPT will be denied with EXyG - Denied due to a lower complex E&M service which was determined after review. CARC 150/ RARC M25
A new line will be added to the claim with the appropriate E&M codes with EXyH - Payment for a reduced rate for a lower complexity E&M service after review

Dispute Process

Providers have 90 days from the date of payment in the Explanation of Payment (EOP) to dispute claims identified as over-coded by submitting a dispute in the Meridian Secure Provider Portal or the YouthCare Secure Provider Portal
Disputes should include supporting documentation or medical records to support the higher-level E&M code
Disputes will be reviewed by a nurse to determine if the records support the level initially billed
If the records support the initial code billed, the over-coding will be overturned and payment adjusted
If the records do not support the initial code billed, the determination will be upheld, and the provider will be notified of the decision

For questions, please contact Meridian Provider Services at 866-606-3700, TTY: 711, Wellcare By Meridian Provider Services at 844-536-2175, TTY: 711, or YouthCare Provider Services at 844-289-2264, TTY: 711.

Thank you for your continued partnership and cooperation to render the highest quality healthcare to our members.