Per case reimbursed admissions only

All inpatient days that are reimbursed under a diagnosis-related group (DRG) and/or per-case payment rate are subject to Medical Necessity review, which may include concurrent review and/or retrospective review. Admissions that have been preapproved will not be retrospectively denied for Medical Necessity unless the Preapproval was based on erroneous information or misinformation provided by the hospital.

Readmissions  

Readmissions are subject to the Inpatient Hospital Readmission policy, which applies to hospitals and health systems paid per case or per admission for inpatient hospital stays.

Ungroupable or invalid DRG 

Claims that are ungroupable or group to an invalid DRG will be denied payment. Claims may be resubmitted by the hospital with corrected data.

Version DRG versus rate effective date 

Unless otherwise specified in the contract, the grouper version used will be based on the contracted version in effect on the date of admission. For all hospitals, the CMS Pricer adjustment factor applied to the DRG pricing will be based on the date of admission.

Per-diem reimbursed admissions only  

All inpatient days that are reimbursed under a per diem payment rate are subject to a concurrent review of Medical Necessity. In the event the hospital fails to provide timely medical information necessary for concurrent review as requested by IBC, inpatient days not reviewed concurrently will be reviewed retrospectively for Medical Necessity. Admissions that have been concurrently reviewed will not be retrospectively denied for Medical Necessity unless the concurrent review was based on erroneous information or misinformation provided by the hospital.

Revenue code groupings

Per diem reimbursement shall be based on bed-type in accordance with the following crosswalk. To the extent that any of the following revenue codes conflict with the Agreement, the terms of the Agreement shall govern

Group  - Medical/surgical

Revenue codes - 0110, 0111, 0112, 0117, 0120, 0121, 0122, 0127, 0130-0132, 0134, 0137, 0140-0142, 0150-0152, 0157, 0206, 0214

Group  - Medical/surgical/pediatric

Revenue codes -0113, 0123, 0133, 0143, 0153

Group  - Intensive care

Revenue codes -0200-0203, 0207-0213, 0219 

Group  - Sub-acute

Revenue codes -0159, 0190-0194, 0199

Group  - Maternity/NICU

Revenue codes - 0170-0174, 0179

Group  - General rehab (non-behavioral health)

Revenue codes - 0118, 0128, 0138, 0148, 0158

Group  - Behavioral health

Revenue codes - 0114, 0116, 0118, 0124, 0126, 0128, 0134, 0136, 0138, 0144, 0146, 0148, 0154, 0156, 0158, 0204