CurrentAnthemPolicy G-01017

Reimbursement Policy Preadmission Services for Inpatient Stays

Defines Anthem Ohio Medicaid reimbursement treatment for outpatient services provided prior to an inpatient hospital admission (the payment window) and which services may be separately reimbursable.

Policy Summary

PayerAnthem

PolicyPreadmission Services for Inpatient Stays

Policy CodePolicy G-01017

Change TypeNo material change

Effective DateSep 11, 2025

Next Review Date

Key ActionDo not separately bill preadmission outpatient services within the payment window for admitting hospitals (3 days) or listed specialty hospitals/units (1 day); CAHs are exempt and may bill separately.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-dayadmitting hospitals window

1-dayspecialty hospitals window

CAH excludedCAH treatment

Ambulance/dialysis/SNFoutside window services

Condition Code 51attestation code

Coverage for Preadmission Outpatient Services

Coverage criteria for preadmission services

Coverage determination depends on facility type, timing relative to admission (the payment window), and service type.

ALL of the following

Included in inpatient reimbursement: All diagnostic outpatient services and admission-related outpatient nondiagnostic services are included in the inpatient reimbursement when they fall within the applicable payment window for the facility type.
May be separately reimbursable (outside payment window or by rule): The following are NOT considered included in the payment window and may be separately reimbursable: ambulance services; maintenance renal dialysis services; services provided by skilled nursing facilities, home health agencies, and hospices; and unrelated nondiagnostic services.

ALL of the following

Policy Summary

PayerAnthem

PolicyPreadmission Services for Inpatient Stays

Policy CodePolicy G-01017

Change TypeNo material change

Effective DateSep 11, 2025

Next Review Date

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.

Billing Codes and Payment Window Details

Billing annotationsmixed

Condition Code 51	Attestation indicating outpatient nondiagnostic services are unrelated to the inpatient admission and billed separately
Modifier PD	Indicates that the service is related to the inpatient admission

Payment window applicability

Admitting hospitals payment windowPreadmission outpatient services are included in inpatient reimbursement for the three days prior to and including the day of admission; not separately reimbursable.

Listed specialty hospitals/units payment windowFor psychiatric hospitals/units, inpatient rehabilitation facilities/units, long-term care hospitals, children's hospitals, and cancer hospitals: included in inpatient reimbursement for one day prior to and including the day of admission; not separately reimbursable.

Critical Access Hospitals (CAH)The three-day and one-day payment windows do not apply; preadmission services are separately reimbursable from the inpatient stay.

RHC/FQHC all-inclusive rateThe three-day or one-day payment window does not apply to preadmission services included in the RHC or FQHC all-inclusive rate.

Provider Billing and Reimbursement Implications

Billing Rule

Prior Authorization and Reimbursement Implications

Prior authorization is not required for the payment-window rule itself, but providers must be aware that outpatient services rendered within the applicable payment window are generally not separately reimbursable to the admitting hospital and related entities. Admitting hospitals should document dates and clinical necessity clearly in the medical record and on claims to support inclusion in the inpatient payment when appropriate. When submitting claims for services that may fall outside the payment window (or for entities exempt from the window), include supporting documentation and attestation as required by the payer.

Admitting hospitals: do not bill separately for preadmission outpatient services provided within the 3-day window (includes wholly owned/operated entities).
Psychiatric, inpatient rehab, LTCH, children’s, and cancer hospitals/units: do not bill separately for preadmission outpatient services within the 1-day window.
Critical Access Hospitals (CAH): may bill separately for preadmission services (payment window does not apply).
Exclude from payment-window inclusion (may be billed separately): ambulance, maintenance dialysis, SNF/HHA/hospice services, and unrelated nondiagnostic services.
When disputing denials for services billed separately, provide clear documentation of service dates, location (entity type), clinical necessity, and any applicable CMS/state exceptions; include attestation if services occurred outside the defined payment window.

Definitions and Billing Modifiers

Admission Related Outpatient Nondiagnostic Services

DefinitionAdmission Related Outpatient Nondiagnostic Services are services furnished in connection with the principal diagnosis assigned to the inpatient admission.

ScopeThese services, together with all diagnostic outpatient services, are included in the inpatient reimbursement when occurring within the applicable payment window.

Attestation for exclusionA hospital may attest that specific nondiagnostic outpatient services are unrelated to the admission by adding Condition Code 51 so those services can be billed separately.

Condition Code 51

Condition Code 51Denotes the hospital's attestation that outpatient nondiagnostic services are unrelated to the inpatient admission and may be billed separately.

UsageAdd Condition Code 51 to the outpatient nondiagnostic service claim to indicate it is not related to the admission and request separate reimbursement.

Relation to payment windowsServices attested with Condition Code 51 are treated as outside the admission-related inclusion and may be reimbursed separately even if within the payment window when properly attested.

Modifier PD

Modifier PDIndicates that the outpatient service is related to the inpatient admission.

Billing implicationModifier PD signals the service is admission-related and, when within the payment window, would be included in the inpatient reimbursement rather than billed separately.

DocumentationUse Modifier PD on outpatient claims to identify services that are related to the inpatient admission per policy definitions.