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
