Billing & Reimbursement for Hospital Services

Inpatient Services

The purpose of this section is to communicate specific billing requirements and reimbursement policies for inpatient hospital services. Hospitals will be reimbursed for inpatient services according to the terms of their Agreement. To the extent that any of the requirements or policies in this section conflict with the Agreement, the terms of the Agreement shall govern.

Inpatient claims 

 Preapproval 

Preapproval is required for certain services prior to services being performed, including elective inpatient admissions

Inpatient day

 An inpatient day is an admission period that begins at midnight on the day of admission and ends 24 hours later. The midnight-to-midnight method is to be used in reporting inpatient days even if the hospital uses a different definition for other purposes. Any part of an inpatient day, including the day of admission, counts as an inpatient day. The day of discharge is not counted as an inpatient day. 

Inpatient services 

Inpatient services are Covered Services that are diagnostic, therapeutic, or surgical and pursuant to an admission. Reimbursement for inpatient services includes, but is not limited to: 

•  ancillary services 
•  anesthesia care 
•  appliances and equipment
•  diagnostic services 
•  medication and supplies 
•  nursing care 
•  radiology 
•  recovery room services 
•  room and board 
•  surgical procedures (including implantable devices, blood, and blood products)
•  therapeutic items (drugs and biologicals) 

The reimbursement rates for inpatient acute admissions are inclusive of all services provided to the Member during the admission. The rate of payment is determined by the effective date of a Member’s inpatient admission and applies for the length of the admission; therefore, any rate change under the contract during the Member’s stay will not apply.