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EMTALA and Prudent Layperson Standard FAQ

1. What is EMTALA?

2. How does EMTALA impact coding, billing and reimbursement?

3. Who does EMTALA cover?

4. What is the Prudent Layperson Standard?

5. Does the Prudent Layperson (PLP) Standard affect billing and reimbursement?

6. Do all Payers recognize EMTALA and the Prudent Layperson Standard in their payment policies?

7. What, if anything, have regulatory authorities stated regarding the obligation of State Medicaid Programs or Medicaid managed care organizations (MCOs) to reimburse the emergency medicine CPT codes according to the CPT codes submitted to a state or MCO?

8. Is Prudent Layperson applicable to managed care plans?

 

9. How do I assure that the medical necessity for treatment in the emergency department is identified for billing?

Updated May 2024

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors, or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising from the use of such information or material. Specific coding or payment-related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact Jessica Adams, ACEP Reimbursement Director, at (469) 499-0222 or jadams@acep.org

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