Currentblue cross blue shield - michiganPolicy MAPPO 1013

Inpatient hospital care — Medicare Plus Blue PPO (Unlimited inpatient days)

This policy governs coverage, payment, billing, and member cost-sharing for inpatient hospital services under Medicare Plus Blue PPO (both individual and group) for Blue Cross Blue Shield of Michigan members.

Policy Summary

Payerblue cross blue shield - michigan

PolicyInpatient hospital care — Medicare Plus Blue PPO (Unlimited inpatient days)

Policy CodePolicy MAPPO 1013

Change TypeExpanded applicabilityeditorial updates

Effective Date

Next Review Date

Key ActionIf coverage is unclear, seek a coverage determination from Blue Cross before providing noncovered items/services; do not have members sign an ABN and hold member harmless if no prior determination was obtained.

SourceLink

POLICY UPDATE CHANGES

Applies to was updated from groups to both individual and group plans; coverage was expanded to include individuals.

Provider billing instructions and hyperlinks were updated and a revision history section was added.

UnlimitedInpatient hospital days covered

Original MedicarePayment basis

PPSReimbursement method

Not allowedBalance billing

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Inpatient Hospital Coverage Criteria

Inpatient hospital coverage criteria

Inpatient hospital services are covered consistent with Original Medicare with the following payment and frequency provisions:

Coverage is provided consistent with Original Medicare and the Medicare Plus Blue PPO enhanced benefit; members under both individual and group Medicare Plus Blue PPO plans receive unlimited inpatient hospital days.

For individuals, member cost sharing and coverage conditions are determined by Blue Cross; for groups, the group determines cost sharing and coverage conditions.

Payment conditions, payable provider and location rules, CPT/HCPCS coding requirements, diagnosis restrictions, and age restrictions are consistent with Original Medicare.

Frequency: unlimited inpatient hospital days.

See Conditions for payment — Frequency = Unlimited days.

Reimbursement is made through a prospective payment system consistent with Original Medicare; this payment represents payment in full and providers are not allowed to bill the member for the difference between the allowed amount and the charge (no balance billing).

Coding requirement: Report CPT/HCPCS and diagnosis codes to the highest level of specificity and follow Medicare-consistent coding rules.

Member cost sharing: Providers should collect applicable cost sharing (copay, coinsurance, deductible) as determined by Blue Cross for individuals or by the group for group plans; collect only the plan's specified cost share amounts.

Noncovered services and coverage determinations: If coverage is unclear or an item/service may be noncovered, obtain a coverage determination from Blue Cross before providing the service. Providers may not have members sign an Advance Beneficiary Notice (ABN) and must hold the member harmless if no prior coverage determination was obtained.

Benefit verification: To verify benefits and member cost share, providers may use web-DENIS or call 1-866-309-1719.

Coding and Medicare Benefit Period

Inpatient coding rulesmixedCovered

CPT/HCPCS

Report CPT/HCPCS codes to the highest level of specificity; coding and diagnosis restrictions are consistent with Original Medicare.

Original Medicare inpatient benefit period

Benefit period60 full days plus 30 coinsurance days

Renewal ruleBenefit period is renewed when the beneficiary hasn’t been in a hospital or skilled nursing facility for 60 days

Applies toOriginal Medicare Part A inpatient stays

Coverage Determinations and Billing Rules

Prior Authorization

Obtain coverage determination before noncovered services; ABNs prohibited

If there is any question about coverage, obtain a coverage determination from Blue Cross before providing the item or service; do not have members sign an Advance Beneficiary Notice (ABN). If a noncovered item/service is provided without a prior coverage determination, the provider must hold the member harmless for all charges except any applicable cost-share.

Providers may not have members sign an ABN to accept financial responsibility for noncovered items or services.
If coverage is unclear, seek a coverage determination from Blue Cross before providing the item or service.
If a provider provides a noncovered item/service without first obtaining a coverage determination, the member must be held harmless for all charges except for any applicable cost-share.

Key Definitions

Inpatient hospital (facility definition and scope)

DefinitionA facility, other than psychiatric, that primarily provides diagnostic, therapeutic (surgical and nonsurgical) and rehabilitation services by or under physician supervision to admitted patients.

Scope - included servicesDiagnostic, therapeutic and rehabilitation services provided to patients admitted for a variety of medical conditions.

Scope - excluded facilitiesPsychiatric hospitals are excluded from this definition.

Medicare Plus Blue PPO enhanced benefit

Enhanced benefit summaryCoverage for unlimited inpatient hospital care days is provided to members under both individual and Medicare Plus Blue Group PPO plans.

Individual member cost sharingFor individual members, cost sharing and coverage conditions are determined by Blue Cross.