Inpatient Hospital Care
Defines Medicare Plus Blue (Medicare Advantage PPO) coverage and reimbursement rules for inpatient hospital services, applicable to group and individual members under Medicare Plus Blue plans.
No material clinical or coverage changes in this revision.
Inpatient Hospital Coverage & Payment
Inpatient hospital coverage and payment conditions
Medicare Plus Blue covers inpatient hospital services consistent with Original Medicare, with enhanced provisions specified by Blue Cross for plans that select this benefit. Coverage and payment are subject to the following conditions:
Code References & Frequency Limits
| CPT/HCPCS | CPT/HCPCS Code(s): 1 = Code Description. Consistent with Original Medicare. |
| ICD-10 | ICD-10 Code(s): 1 = Code Description. Consistent with Original Medicare. |
| HCPCS | HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare and Medicaid Services (CMS). |
| ICD-10 | ICD-10 codes, descriptions and materials are copyrighted by the World Health Organization (WHO). |
Provider Verification, Billing & Coverage Determination
Pre-service verification and coverage determination
Verify member benefits and the applicable Medicare Plus Blue cost share before providing services. Use the provider portal or call the number below; if there is any question about coverage or whether an item is covered, obtain a coverage determination from Medicare Plus Blue before delivering noncovered items.
- To verify benefits and cost-share, providers may utilize our provider portal or call 1-866-309-1719.
- If there is any question about whether an item is covered, seek a coverage determination from Medicare Plus Blue before providing the item to the member.
- If a provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share.
Key Definitions
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