CurrentHumanaPolicy CP2023008

Payment Window for Outpatient Services Treated as Inpatient Services

This policy describes Humana's claims payment treatment when outpatient services provided prior to an inpatient admission are bundled into the inpatient reimbursement (the CMS payment window) and applies to Medicare Advantage and Commercial products and providers submitting claims to Humana.

Policy Summary

PayerHumana

PolicyPayment Window for Outpatient Services Treated as Inpatient Services

Policy CodePolicy CP2023008

Change TypeNo material change

Effective Date

Next Review Date

Key ActionEnsure claims comply with plan requirements including medical necessity, reasonableness, and any applicable referral or authorization rules before submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantage & CommercialProducts to which this policy applies

3-day (or 1-day)Payment window recognized

CMS Chapters 3 & 4Primary external guidance

MonthlyEdit notifications

Payment window processing

Payment window processing criteria

Humana allows claims subject to the CMS payment window to be processed consistent with applicable CMS guidance; related preadmission outpatient claim reimbursement may offset inpatient claim payment when the outpatient claim was adjudicated prior to the inpatient claim.

Claims subject to the CMS payment window are processed consistent with applicable CMS guidance (payment window for outpatient services treated as inpatient services).

An inpatient claim may be offset by the amount reimbursed for a related preadmission outpatient claim if that outpatient claim was adjudicated prior to the submission of the inpatient claim (per CMS guidance).

Claims remain subject to other plan requirements such as medical necessity, reasonableness, and applicable referral or authorization requirements before payment under the payment window is determined.

Payment window definition: CMS policy that certain outpatient services provided prior to an inpatient admission are bundled into the reimbursement for the inpatient admission (also known as the 3-day or 1-day payment window).

Policy Summary

PayerHumana

PolicyPayment Window for Outpatient Services Treated as Inpatient Services

Policy CodePolicy CP2023008

Change TypeNo material change

Effective Date

Next Review Date

Key ActionEnsure claims comply with plan requirements including medical necessity, reasonableness, and any applicable referral or authorization rules before submission.

SourceLink

On This Page

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.

Plan requirements and prior authorization

Prior Authorization

Plan requirements and prior authorization note

Claims remain subject to plan requirements before payment determination. Providers must meet medical necessity and reasonableness standards and any applicable referral or authorization requirements; failure to meet these plan requirements may affect claim adjudication and payment under the payment window rules.

Ensure services meet medical necessity and reasonableness prior to claim submission.
Verify and obtain any required referrals or prior authorizations per the member’s plan before providing services.
Be aware that an inpatient claim may be offset by reimbursement already paid for a related preadmission outpatient claim adjudicated prior to the inpatient claim.

Key definitions

Payment window for outpatient services treated as inpatient services

DefinitionPayment window for outpatient services treated as inpatient services: CMS policy that certain outpatient services provided prior to an inpatient admission are bundled into the reimbursement for the inpatient admission (also known as the 3-day or 1-day payment window).

ScopeApplies when outpatient services related to an inpatient admission were provided prior to the inpatient admission and may be included in inpatient reimbursement under CMS guidance.

Alternate name3-day (or 1-day) payment window.

Effect on claimsA related preadmission outpatient claim may offset or be bundled into the inpatient claim reimbursement per CMS payment window rules.

Plan applicabilityHumana follows CMS guidance for processing these claims; claims remain subject to plan requirements such as medical necessity and authorization rules.

OpenPayer

Payment Window for Outpatient Services Treated as Inpatient Services

Payment window processing

CMS payment window guidance and coding references

Plan requirements and prior authorization

Key definitions