Currentblue cross blue shield - michiganPolicy BCPFFS 1004

Inpatient hospital care (Blue Cross Medicare PFFS)

Defines coverage, payment, and billing rules for inpatient hospital services for Blue Cross Medicare Private Fee-for-Service (PFFS) members; aligns benefits and reimbursement with Original Medicare while noting plan-specific cost sharing and billing procedures.

Policy Summary

Payerblue cross blue shield - michigan

PolicyInpatient hospital care (Blue Cross Medicare PFFS)

Policy CodePolicy BCPFFS 1004

Change TypeNo material changes

Effective DateJan 1, 2017

Next Review Date

Key ActionBill inpatient hospital services on CMS-1450 (UB-04) or 837 equivalent, report CPT/HCPCS and diagnosis codes to the highest level of specificity, include NPI on all claims, and submit claims to the local BCBS plan using electronic billing where available.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UnlimitedInpatient hospital days covered under Blue Cross Medicare PFFS

Original MedicareEligible provider/payment conditions, HCPCS, diagnosis and age restrictions

ProspectiveReimbursement method (payment in full; no balance billing)

Conditions for Payment

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All of the following must be met

Eligible provider requirements: consistent with Original Medicare.
Payable location requirements: consistent with Original Medicare.
Frequency: unlimited inpatient days under Blue Cross Medicare PFFS.
Blue Cross Medicare PFFS provides coverage for unlimited inpatient hospital care days; member cost sharing and coverage conditions are determined by the plan.
HCPCS codes: consistent with Original Medicare.
Diagnosis restrictions: consistent with Original Medicare.
Age restrictions: consistent with Original Medicare.

Claim Forms, Codes, and Reporting

Claim form and code reportingmixed

CMS-1450 (UB-04)	Institutional claim form to bill inpatient hospital services (or 837 equivalent)
ANSI ASC X12N 837	837 Institutional Health Care Claim (electronic submission)
ANSI ASC X12N 835	835 Electronic Remittance Advice

Claim form and code reportingmixed

No codes listed

Billing Rule

Claims submission and coding

Bill services on CMS-1450 (UB-04) or 837 equivalent. Report CPT/HCPCS and diagnosis codes to highest level of specificity. Include National Provider Identifier on all claims. Submit claims to the local BCBS plan. Use electronic billing where available; see BCBSM EDI documentation for 837/835 companion documents.

Affected claim forms/codes: CMS-1450 (UB-04), ANSI ASC X12N 837, ANSI ASC X12N 835, CPT, HCPCS, NPI
Submit claims to the member's local BCBS plan
For electronic billing and companion documents see: http://www.bcbsm.com/providers/help/faqs/electronic-connectivity-edi.html

Documentation Required

Where to find electronic billing specifications

ANSI ASC X12N 837 and 835 institutional companion documents are available on the BCBSM website; Michigan providers should use the BCBSM EDI Institutional 837/835 Companion Documents. Providers outside Michigan should contact their local BCBS plan for EDI guidance.

Michigan providers: BCBSM EDI Institutional 837/835 Companion Documents (BCBSM website reference library)
Providers outside Michigan: contact your local BCBS plan for EDI guidance
Reference: http://www.bcbsm.com/providers/help/faqs/electronic-connectivity-edi.html

Actions Providers Must Take

Billing Rule

Collecting member cost share

Collect applicable Blue Cross Medicare PFFS cost sharing (copayment, coinsurance, deductible) from the member at time of service when possible. If the member elects a non-covered service, collect the full charge.

Verify benefits and cost share via web-DENIS or by calling 1-866-309-1719

Denial Risk

Balance billing prohibited

Reimbursement under the Blue Cross Medicare PFFS plan is payment in full through a prospective payment system consistent with Original Medicare; providers are not allowed to balance bill the member for the difference between the allowed amount and the charge.

Providers may not balance bill members; the plan's payment is payment in full under the prospective payment system consistent with Original Medicare

Scope and Administrative Context

Defines coverage, payment, and billing rules for inpatient hospital services for Blue Cross Medicare Private Fee-for-Service (PFFS) members; aligns benefits and reimbursement with Original Medicare while noting plan-specific cost sharing and billing procedures. The policy specifies that unlimited inpatient hospital days are covered under the Blue Cross Medicare PFFS plan, reimbursement follows the prospective payment system consistent with Original Medicare (payment in full; no balance billing), and providers must collect the member's applicable PFFS cost sharing (copayment, coinsurance, deductible) at time of service when possible and verify benefits via web-DENIS or 1-866-309-1719.

Defined Terms

Definitions

Inpatient hospitalA facility, other than psychiatric, that primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by or under the supervision of physicians to patients admitted for a variety of medical conditions.

Blue Cross Medicare PFFSA Medicare Advantage Private Fee-for-Service plan that at minimum provides the same benefits as Original Medicare and may offer enhanced benefits; plan determines member cost sharing and coverage conditions.