CurrentAnthemPolicy C-18002

Newborn Inpatient Stays - Facility

Defines Anthem's reimbursement rules for newborn inpatient stays for facility claims, including DRG and revenue-code matching and neonatal levels of care; applies to commercial lines per the policy header.

Policy Summary

PayerAnthem

PolicyNewborn Inpatient Stays - Facility

Policy CodePolicy C-18002

Change TypeRevised / Added / Removed

Effective Date01/01/2026

Next Review Date

Key ActionCurrent authorization guidelines for newborn inpatient stays will be applied.

SourceLink

POLICY UPDATE CHANGES

Updated the revenue code comments in the Related Coding section to reflect the latest Clinical UM Guidelines.

Added Section I. DRG Newborn Revenue Code Mismatch.

Retired Neonatal policy C-15001 and consolidated revenue code level and complexity descriptions into this policy.

5neonatal revenue code levels described (0170-0174)

C-18002policy identifier

01/01/2026effective date

10/01/2025last approval date

Newborn inpatient reimbursement criteria

Covered when ALL of the following are met:

The health plan allows reimbursement for newborn inpatient stays unless provider, state, federal, or contract requirements indicate otherwise (see applicable benefit and regulatory provisions).

When reimbursement is DRG-based, claims must include the appropriate neonatal revenue code to group to the correct newborn DRG; absence of a NICU revenue code on the claim will prevent grouping to a sick newborn DRG.

When reimbursement is revenue-code-based, use revenue codes 0170–0174 consistent with the neonatal level definitions (General Nursery/Well-Baby through Level IV NICU) to determine payment level.

Well-baby nursery eligibility: infants weighing >=2000 grams at birth and clinically stable infants >=35 weeks gestational age may be cared for in a well-baby (General Nursery) setting; phototherapy, IV fluids/medications, and antibiotic therapy are not appropriate for General Nursery level of care.

Policy Summary

PayerAnthem

PolicyNewborn Inpatient Stays - Facility

Policy CodePolicy C-18002

Change TypeRevised / Added / Removed

Effective Date01/01/2026

Next Review Date

Key ActionCurrent authorization guidelines for newborn inpatient stays will be applied.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Neonatal revenue codes, levels and well-baby eligibility

Neonatal revenue codes and level descriptionsRevenue

0170	General Nursery or Well-Baby Nursery. For healthy neonates who are physiologically stable and receiving evaluation and observation in the immediate post-partum period; care may take place in a nursery or in the birth mother's room ('maternal rooming-in'). Infants weighing 2000 grams or more at birth and clinically stable infants at 35 weeks gestational age or greater may be cared for in a well-baby nursery. This is not a neonatal intensive care level. Phototherapy, intravenous (IV) fluids or medications and antibiotic therapy are not appropriate for General Nursery or Well-Baby Nursery level of care.
0171	Level I Surveillance 'Special Care Nursery'. Covers neonates who are medically stable but require surveillance/care at a higher level than provided in the general nursery.
0172	Level II Neonatal Intensive Care. Newborns admitted or treated at this level are those with physiological immaturity combined with medical instabilities.
0173	Level III Neonatal Intensive Care. Directed at those neonates that require invasive therapies and/or are critically ill with respiratory, circulatory, metabolic, or hematologic instabilities and/or require surgical intervention with general anesthesia.
0174	Level IV Neonatal Intensive Care. Covers hemodynamically unstable or critically ill neonates including those with respiratory, circulatory, metabolic or hemolytic instabilities, conditions that require surgical intervention, and the first 24 hours of monitoring of infants with major congenital anomalies or extreme prematurity who are at risk for hemodynamic instability.

Well-baby nursery eligibility by weight/gestational age

Well-baby nursery weight thresholdInfants weighing 2000 grams or more at birth may be cared for in a well-baby nursery.

Well-baby nursery gestational age thresholdClinically stable infants at 35 weeks gestational age or greater may be cared for in a well-baby nursery.

Stability requirementInfants must be physiologically stable to qualify for General Nursery/Well-Baby Nursery care.

Care settingCare may take place in a nursery or in the birth mother's room (maternal rooming-in).

Services not appropriatePhototherapy, intravenous fluids or medications, and antibiotic therapy are not appropriate for General Nursery/Well-Baby Nursery level of care.

Revenue code level definitions

0170 — General Nursery / Well-Baby Nursery

Code0170

Short descriptionGeneral Nursery or Well-Baby Nursery (healthy, physiologically stable neonates; not NICU)

Key commentFor healthy neonates who are physiologically stable and receiving evaluation and observation in the immediate post-partum period; care may occur in nursery or maternal rooming-in.

0171 — Level I Surveillance 'Special Care Nursery'

Code0171

Short descriptionLevel I Surveillance 'Special Care Nursery' (medically stable but require higher surveillance than general nursery)

Key commentCovers neonates who are medically stable but require surveillance/care at a higher level than provided in the general nursery.

0172 — Level II Neonatal Intensive Care

Code0172

Short descriptionLevel II Neonatal Intensive Care (physiologic immaturity with medical instabilities)

Key commentNewborns admitted or treated at this level are those with physiological immaturity combined with medical instabilities.

0173 — Level III Neonatal Intensive Care

Code0173

Short descriptionLevel III Neonatal Intensive Care (critically ill or requiring invasive therapies/surgery)

Key commentDirected at neonates that require invasive therapies and/or are critically ill with respiratory, circulatory, metabolic, or hematologic instabilities and/or require surgical intervention with general anesthesia.

0174 — Level IV Neonatal Intensive Care

Code0174

Short descriptionLevel IV Neonatal Intensive Care (hemodynamically unstable or critically ill; major congenital anomalies/extreme prematurity monitoring)

Key commentCovers hemodynamically unstable or critically ill neonates including those with respiratory, circulatory, metabolic, or hemolytic instabilities, and includes first 24 hours of monitoring of infants with major congenital anomalies or extreme prematurity at risk for hemodynamic instability.

OpenPayer

Newborn Inpatient Stays - Facility

Newborn inpatient reimbursement criteria

Neonatal revenue codes, levels and well-baby eligibility

Authorization and billing actions

Revenue code level definitions