CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payments for Outpatient Service Performed when a Member is Admitted as an Inpatient to a Different Hospital

This policy governs how Blue Cross & Blue Shield of Rhode Island (BCBSRI) reimburses providers when an inpatient is transported to another hospital or freestanding provider to receive outpatient services and then returned to the admitting hospital; it affects BCBSRI, its network hospitals, and providers furnishing such outpatient services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayments for Outpatient Service Performed when a Member is Admitted as an Inpatient to a Different Hospital

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2011

Next Review DateN/A

Key ActionThe inpatient facility is generally responsible for reimbursing outpatient services performed elsewhere, though BCBSRI may separately reimburse certain professional components (example: radiation professional component).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

inpatient facilityFacility reimbursement responsibility

professional reimbursedProfessional component reimbursed

Ambulance: GroundRelated policy

06/05/2018Last review

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.

Reimbursement Rules

Reimbursement rules for outpatient services provided to admitted inpatients

Reimbursement stance when outpatient services are provided to an admitted inpatient at another facility:

BCBSRI will reimburse the hospital where the member is admitted under its contractual inpatient arrangements (e.g., Diagnosis Related Group [DRG], per case, or other methodology), which is all‑encompassing and represents the total amount allowed (less any member responsibility).

Services performed by another hospital, facility, or freestanding provider while the member is inpatient will not be reimbursed separately by BCBSRI; reimbursement for those services is the responsibility of the inpatient facility.

Exception

BCBSRI will reimburse separately for services that, when rendered in the inpatient setting, are separately reimbursable professional services (example: BCBSRI would reimburse the professional component to a radiation treatment provider).

For coverage of ambulance services in these situations, refer to the Ambulance: Ground Policy.

Relevant Codes

Codingmixed

No codes listed

Prior Authorization and Billing Actions

Note

Definitions and Scope

Outpatient services performed while admitted as inpatient at different hospital

DefinitionWhen an admitted inpatient is transported to another hospital or freestanding provider to receive outpatient services and then returned to the admitting hospital; reimbursement responsibilities are clarified between the admitting inpatient facility and the providing outpatient facility.

Primary reimbursement ruleBCBSRI will reimburse the hospital where the member is admitted under its contractual inpatient arrangements (e.g., DRG, per case), which is all‑encompassing and represents the total amount allowed.

Responsibility for services performed elsewhereServices performed by another hospital, facility, or freestanding provider while the member is inpatient will not be reimbursed separately by BCBSRI; reimbursement for those services is the responsibility of the inpatient facility.

Exception — separately reimbursable professional servicesBCBSRI will reimburse separately for services that, when rendered in the inpatient setting, are separately reimbursable professional services (example: professional component for radiation treatment may be reimbursed to the radiation provider).

Related policy