Medicare Advantage

This policy applies to facility providers billing on a CMS-1450 (UB-04) claim form, or the equivalent 837i form, for Medicare Advantage members enrolled in Medicare Advantage products.​​​​​ This policy applies to participating hospitals and hospital health systems reimbursed based on DRG/case rate methodologies. The policy does not apply to participating hospitals and hospital health systems reimbursed on a per diem basis.

For purposes of payment determination under this policy, the criteria, definitions, and requirements set forth herein supersede the Hospital Manual, including but not limited to the Hospital Manual's definition of admission review. The Hospital Manual's definition of admission may continue to apply for other operational and payment determination purposes not governed by this payment policy. To the extent necessary, the Hospital Manual will be updated to align. However, until revisions to the Hospital Manual are issued, this payment policy shall prevail.

This policy establishes the Company's claim payment policy regarding emergent inpatient admissions of up to and including five (5) inpatient days. THIS POLICY DOES NOT AFFECT COVERAGE DETERMINATIONS. All coverage determinations are made by the Company based on CMS regulations and guidance, benefit plan documents and contracts, and the member's medical history and condition.

The intent of this policy is to address the Company's claim payment policy for emergent inpatient admissions, up to and including inpatient day five (5), for facility providers reimbursed based on DRG/case rate methodologies.

When a member is emergently admitted to a hospital, for up to and including 5 inpatient days, and determination of coverage at the acute inpatient level of care has been issued by the Company, the Company shall determine the payment amount for the covered inpatient hospital stay based on the following intensity of services criteria:

• Payment will be made at the provider's contracted acute inpatient DRG rate when the medical records submitted to the Company for the admission are determined to meet InterQual acute inpatient criteria. This is not a medical necessity review for inpatient services, but instead a payment level review.

• Payment will be made at the provider's contracted observation rate when the medical records submitted to the Company for the admission are determined to not meet InterQual acute inpatient criteria. This is not a medical necessity review for inpatient services, but instead a payment level review, and does not affect the coverage determination.
  

Time spent in custodial care, delays in care, including for procedures, or delays in post-discharge planning are not included in the calculation of the length of the member's stay.

InterQual criteria will not be used to determine whether an inpatient stay is medically necessary. Instead, InterQual criteria will be used to determine the level of payment made for emergent inpatient admissions. Providers have the option to request a review of the payment determination (including the right to have a discussion with a Company Medical Director), and to dispute the payment determination under this policy, if they believe the admission meets InterQual acute inpatient criteria.

POLICY EXCEPTIONS

The intensity of services payment policy does not apply to the following:

• Cases involving an unexpected death, CMS inpatient-only procedures, and newly initiated mechanical ventilations. In those instances, the hospital will be reimbursed at the acute inpatient DRG rate.

• Behavioral health admissions, long-term acute care inpatient admissions, and acute rehabilitation confinements.

REQUIRED DOCUMENTATION

The individual's medical record is used to determine the level of payment as described above. These medical records may include but are not limited to records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.