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. For detailed information on Preapproval, please refer to the Care Management and
Coordination section of this manual.
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.
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