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 

Present on admission (POA) indicator

All acute care hospitals are required to follow instructions from the Centers for Medicare & Medicaid Services (CMS) regarding the identification of the POA indicator for all diagnosis codes for inpatient claims. Claims submitted without a valid POA indicator will be rejected. Consistent with the CMS requirements for POA indicators, the following facility types are exempt:

 critical access hospitals 

 long-term care hospitals 

 cancer hospitals 

 children’s inpatient facilities 

 inpatient rehabilitation facilities

 psychiatric hospitals 

Member enrollment during an admission 

IBC payment responsibility varies depending on the Member’s coverage, as summarized below: 

 Commercial HMO and PPO Members. IBC is required to cover the admission from the Member’s enrollment date in an IBC plan. If a Member enrolls in a Commercial plan from another Commercial HMO plan, the previous plan should cover the Member’s entire admission. 

 Medicare Advantage HMO and PPO Members. Original Medicare covers the Member through to the discharge date.

If the Member’s benefits plan or regulations conflict with these provisions, actual payments may vary.

Member termination during an admission 

IBC payment responsibility varies depending on Member coverage and provider payment methodology, as summarized below: 

Payment methodology	Line of business
	Commercial HMO and Medicare Advantage HMO/PPO	Commercial PPO
Per diem	Pays to the discharge date	Pays to the last covered day
Per case	Pays the entire case rate	Pays the entire case rate
Percent of charge	Pays to the discharge date	Pays to the last covered day

If the Member’s benefits plan or regulations conflict with these provisions, actual payments may vary

Maternity admissions 

Reimbursement for maternity admissions is inclusive of the mother and newborn days while the mother is inpatient. Neonatal intensive care unit (NICU) and transitional nursery days are paid separately regardless of mother’s status as inpatient. 

 Normal delivery claims. When billing newborn baby charges (e.g., revenue code 0170, 0171, 0172, or 0179) the maternity charges for mother and baby must be combined on the same UB-04 form. NICU charges should also be added to the mother’s inpatient bill using revenue code 0173 or 0174. 

 Detained baby claims. If the baby remains hospitalized after the mother is discharged (i.e., detained baby), a new admission with its own Preapproval is required. The detained baby’s admission date is the same date as the mother’s discharge date. A separate claim for the detained baby’s admission is required. 

 For Members with Federal Employee Program (FEP) coverage. In those cases where the baby requires a higher level of care and is considered sick while the mother is still hospitalized, a separate admission for the baby is needed. The baby’s admission requires its own Preapproval. The baby’s claim is to be billed using either revenue code 0173 or 0174, and the admission date is the same as the Preapproval date.

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. For additional information on readmissions, please refer to our medical policies at www.ibx.com/medpolicy. 

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	Revenue codes
Medical/surgical	0110, 0111, 0112, 0117, 0120, 0121, 0122, 0127, 0130-0132, 0134, 0137, 0140-0142, 0150-0152, 0157, 0206, 0214
Medical/surgical/pediatric	0113, 0123, 0133, 0143, 0153
Intensive care	0200-0203, 0207-0213, 0219
Sub-acute	0159, 0190-0194, 0199
Maternity/NICU	0170-0174, 0179
General rehab (non-behavioral health)	0118, 0128, 0138, 0148, 0158
Behavioral health	0114, 0116, 0118, 0124, 0126, 0128, 0134, 0136, 0138, 0144, 0146, 0148, 0154, 0156, 0158, 0204

Maternity admissions

Reimbursement for maternity admissions is inclusive of the mother and newborn days while the mother is inpatient. Neonatal intensive care unit (NICU) and transitional nursery days are paid separately regardless of mother’s status as inpatient.

Normal delivery claims. When billing newborn baby charges (e.g., revenue code 0170, 0171, 0172, or 0179) the maternity charges for mother and baby must be combined on the same UB-04 form. NICU charges should also be added to the mother’s inpatient bill using revenue code 0173 or 0174. 

Detained baby claims. If the baby remains hospitalized after the mother is discharged (i.e., detained baby), a new admission with its own Preapproval is required. The detained baby’s admission date is the same date as the mother’s discharge date. A separate claim for the detained baby’s admission is required. 

For Members with Federal Employee Program (FEP) coverage. In those cases where the baby requires a higher level of care and is considered sick while the mother is still hospitalized, a separate admission for the baby is needed. The baby’s admission requires its own Preapproval. The baby’s claim is to be billed using either revenue code 0173 or 0174, and the admission date is the same as the Preapproval date.

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. For additional information on readmissions, please refer to our medical policies at www.ibx.com/medpolicy. 

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