Hospital Acquired Conditions (HAC)
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Defines Healthfirst reimbursement rules for inpatient hospital-acquired conditions (HACs), including POA reporting and documentation requirements, and lists affected lines of business and facility exemptions. Applies to hospitals submitting inpatient claims to Healthfirst of New York.
No material clinical or coverage changes in this revision.
Reimbursement Rules for Hospital-Acquired Conditions
Reimbursement criteria for HACs
Healthfirst's stance on reimbursement for listed HACs in inpatient settings:
POA payment conditions
- POA indicator 'Y' — The condition was present on admission; payment will be made.
- POA indicator 'W' — The condition could not be clinically determined as present on admission but is supported by documentation; payment will be made.
POA Indicators and Coding Requirements
| POA:Y/N/U/W/1 | Present on Admission indicator values; 'Y' = present and paid, 'N' = not present and not paid, 'U' = insufficient documentation not paid, 'W' = clinically undetermined and paid, '1' = POA-exempt (must not be used for HAC codes). |
Reporting, Documentation, and Claims Adjudication
POA reporting and documentation
Hospitals must report a Present on Admission (POA) indicator for each diagnosis on inpatient claims using UB-04 Field Locator 67 (and 67 A–Q for paper) or the 837I per UB-04 specifications. Accurate, complete medical record documentation must be provided by any licensed provider involved in the patient’s care; POA indicators must be appropriately sequenced and coded in alignment with ICD-10-CM and official coding guidelines. Billing offices and third‑party agents are responsible for maintaining the integrity of code sequencing and POA accuracy.
- Report POA on UB-04: Field Locator 67 and 67 A–Q (paper claims).
- Report POA on 837I per UB-04 Data Specifications Manual (electronic claims).
- Ensure documentation comes from licensed providers and supports coded diagnoses.
- Sequence and code POA indicators per ICD-10-CM and official coding guidelines.
- Billing offices and third‑party agents must maintain POA and code sequencing integrity.
Claims adjudication and appeals
Claims that do not adhere to this HAC policy may be denied or rejected; providers are responsible for ensuring claims are coded accurately and must follow provider contract timely filing requirements. Providers may pursue reconsideration or appeals per the Healthfirst Provider Manual (subsection 17.6) and final reimbursement depends on benefit coverage, mandates, medical necessity, and the provider contract.
- Non‑adherent claims may be denied or rejected — ensure accurate coding before submission.
- Claims are subject to timely filing rules in the provider contract and Provider Manual subsection 17.6.
- Appeals and reconsideration processes are available as described in the Provider Manual.
Key Terms
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