This administrative policy describes Blue Cross & Blue Shield of Rhode Island’s payment rules for local in‑network hospitals that are reimbursed under a DRG or Case Rate methodology, and governs transfers between short‑term acute care hospitals, outpatient services provided shortly before an inpatient admission, and services provided by other providers while a patient remains an inpatient. It applies only to local in‑network facilities reimbursed as DRG/Case Rate hospitals; individual hospital contract language supersedes this policy.
When a member is transferred from one acute care hospital to another and the transferring hospital is reimbursed as a DRG or case rate, the transferring hospital will be paid on a graduated per diem rate for each day of the stay when the length of stay is less than the DRG’s geometric mean or average length of stay (depending on the contracted grouper). The per diem is calculated by dividing the full DRG payment by the DRG’s geometric mean or average length of stay, and payment to the transferring hospital will not exceed the full DRG/case rate payment.
If the receiving acute care hospital ultimately discharges the transferred patient, the receiving facility receives the full DRG payment based on the new admitting diagnosis. Transfer reductions do not apply when the patient is discharged to a long‑term care facility, rehabilitation or psychiatric hospital, a skilled nursing facility, or to home health services.
Outpatient diagnostic, observation, related therapeutic or related non‑diagnostic services furnished by the admitting facility or an entity wholly owned or operated by the admitting facility within three (3) days prior to admission are combined into the inpatient admission payment and must not be billed separately. Any items/supplies integral to a diagnostic procedure (for example, pharmacy items or injections given for a diagnostic radiology procedure) are also combined. Services that are explicitly not combined include home health agency, skilled nursing facility, hospice, maintenance renal dialysis, physician professional services, and screening mammography.
When an inpatient is transported to another hospital, facility, or freestanding provider for services and remains an inpatient, BCBSRI will not separately reimburse those other providers unless the service is separately reimbursable when rendered in the inpatient setting (for example, professional services). Reimbursement responsibility for other services performed while the member remains an inpatient lies with the inpatient facility.
Administrative note: Individual hospital contract language supersedes this policy. Case rate methodology varies by hospital contract. Transfer cases remain eligible for outlier payments per policy.