CurrentMass General Brigham Health PlanPolicy N/A

Inpatient Newborn Care — Reimbursement and Billing Guidelines

This payment policy governs reimbursement and billing guidelines for medically necessary inpatient newborn care provided in participating facilities to Mass General Brigham Health Plan members, including coding, DRG and circumcision reimbursement rules, and special instructions for MassHealth births.

Policy Summary

PayerMass General Brigham Health Plan

PolicyInpatient Newborn Care — Reimbursement and Billing Guidelines

Policy CodePolicy N/A

Change TypeAnnual review (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for all inpatient services except routine newborn delivery; submit required MassHealth Notification of Birth within 30 days for MassHealth births.

SourceLink

POLICY UPDATE CHANGES

Annual review on January 1, 2025 noted as 'no policy change'.

January 1, 2019 restructure updated codes, descriptors and references.

30MassHealth Notification timeframe (days)

MultipleExample codes referenced

Covered (no separate reimbursement)Routine newborn nursery charges

RequiredAuthorization requirement

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Inpatient newborn coverage and exclusions

Coverage stance and specific rules:

ALL of the following

ONE OF
- Circumcision requested by the parent and performed by a participating provider while the newborn is in the hospital following delivery (reimbursed under the inpatient stay).
- Inpatient physician services for the newborn.
- State-mandated diagnostic testing and screening.

ALL of the following

Submit claims for the delivery under the mother’s Mass General Brigham Health Plan member ID and submit nursery claims under the newborn’s Mass General Brigham Health Plan member ID.
Routine nursery charges are covered but not reimbursed separately for the commercial line; all incurred inpatient services are included in the obstetrical payment when the mother is an MGBHP member.

ALL of the following

Sick newborns transferred to the NICU or another facility are reimbursed using the newborn’s Mass General Brigham Health Plan identification number and corresponding authorization number.
Well newborn care during and after the inpatient stay and the mother’s discharge is reimbursed using the newborn’s Mass General Brigham Health Plan identification and corresponding authorization numbers.

ALL of the following

Ritual circumcision performed by non-clinicians is not reimbursed.

ALL of the following

Routine circumcision requested and performed by a participating provider during the newborn's hospital stay is reimbursed as part of the inpatient stay (not separately billed).
Use the newborn’s member ID and authorization number for nursery claims and for transfers to higher level care.

Procedure, Revenue, DRG and Claim Data Elements

Example Procedure and Revenue Codesmixed

0169	Room & Board other - administratively necessary days; use per contractual agreement.
0170	Newborn nursery - routine newborn care.
0171	Newborn level - routine newborn care.
0172	Newborn level II.
0173	Newborn level III.
0174	Newborn level IV.
54150	Circumcision, using clamp or other device with regional dorsal penile or ring block.
54160	Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days or less).

Minimum DRG claim data elements

ICD/Procedure CodesICD-CM diagnosis codes; ICD-CM procedure codes

Patient DemographicsDate of Birth; Gender; Birthweight (when applicable)

Admission / DischargeAdmit Date; Discharge Date; Status of Discharge

Clinical/Support DataDays on Mechanical Ventilator (value or ICD-10-CM code)

Relevant E&M/Neonatal CPT Codes99460-99463, 99464-99465, 99468-99469, 99477-99480

Authorization, Referral, Claims Audit and Eligibility

Prior Authorization

Prior Authorization Required

Prior authorization is required for all inpatient services (except routine newborn delivery). Providers must obtain authorization prior to admission per plan-specific utilization management requirements.

Applies to all inpatient admissions except routine newborn delivery
Authorization must be obtained prior to admission per member's benefit plan

Documentation Required

Claims Audit, Eligibility, DRG and Appeals

All claims are subject to audit. Mass General Brigham Health Plan may request medical records to verify services, eligibility, and coding. Claims payment is subject to member eligibility, coordination of benefits, referral/authorization/notification, utilization management guidelines, claims editing logic, and the provider contract. Providers should ensure DRG claims contain the minimum documentation and coding required; if a claim cannot be grouped due to insufficient data it will be rejected and returned. If the submitted DRG differs from the system-assigned DRG, the plan-assigned DRG will prevail; providers may appeal with supporting medical records.

All claims subject to audit — medical records may be requested
Claims payment depends on member eligibility, benefits, coordination of benefits, and applicable referrals/authorizations
DRG claims must include required documentation; insufficient data will result in rejection
If submitted DRG differs from system DRG, plan-assigned DRG takes precedence; providers may appeal with documentation

Definitions and Reimbursement Notes

inv-06: Coding Elements used for APR-DRG subclass assignment

APR‑DRG diagnosis and procedure codesICD‑CM diagnosis codes and ICD‑CM procedure codes are used to assign APR‑DRG subclasses

Patient demographicsDate of Birth and Gender are used in subclass assignment

BirthweightBirthweight is included when applicable for APR‑DRG subclassification

Care dates and dispositionAdmit Date, Discharge Date, and Status of Discharge inform APR‑DRG subclass assignment

Ventilator daysDays on Mechanical Ventilator (reported as a value or ICD‑10‑CM code) are used for subclass assignment

inv-07: Routine circumcision reimbursement

Routine circumcision coverageRoutine circumcision requested and performed by a participating provider during the newborn's hospital stay is reimbursed under the inpatient stay

Sick newborn transfersSick newborns transferred to the NICU or another facility are reimbursed using the baby’s Mass General Brigham Health Plan ID and corresponding authorization number

Well newborn care billingWell newborn care during and after the inpatient stay and at the mother's discharge is billed using the baby’s Mass General Brigham Health Plan ID and corresponding authorization numbers

Policy Summary

PayerMass General Brigham Health Plan

PolicyInpatient Newborn Care — Reimbursement and Billing Guidelines

Policy CodePolicy N/A

Change TypeAnnual review (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for all inpatient services except routine newborn delivery; submit required MassHealth Notification of Birth within 30 days for MassHealth births.

SourceLink

On This Page

OpenPayer

Inpatient Newborn Care — Reimbursement and Billing Guidelines

Inpatient Newborn Coverage and Exclusions

Procedure, Revenue, DRG and Claim Data Elements

Authorization, Referral, Claims Audit and Eligibility

Definitions and Reimbursement Notes