CurrentMass General Brigham Health PlanPolicy N/A

Provider Payment Guidelines

Governs reimbursement and billing guidelines for medically necessary inpatient hospital services for Mass General Brigham Health Plan participating hospitals, including DRG billing and related coding requirements.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Payment Guidelines

Policy CodePolicy N/A

Change TypeDocument restructureMS-DRG incorporation

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for all inpatient services except routine newborn delivery per the member's benefit plan.

SourceLink

POLICY UPDATE CHANGES

Document restructure; added DRG billing guidelines, remove definitions

Document restructure; codes, code descriptor and references updated

Document rebrand, incorporated MS-DRG's for Medicare Advantage

Annual review; added MassHealth Acute Carve-Out Drug link

Removed phrase 'only when prior authorized under medical necessity'

POA requiredPOA requirement

APR-DRG / MS-DRGDRG methodologies

Routine newborn deliveryNewborn exception

MultipleRevision entries

MassHealth, Medicare

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Inpatient Coverage and Payment Rules

Inpatient coverage and billing rules

Mass General Brigham Health Plan reimburses medically necessary inpatient services per member benefit and provider contract; certain items are not reimbursed. Covered and excluded services, plus billing rules, are summarized below.

Inpatient acute medical admissions are reimbursed when notified within appropriate timeframes and when services meet medical necessity and member benefit definitions.

Providers are reimbursed according to the plan's network provider reimbursement or contracted rates; member liability (copayment, deductible, coinsurance) applies per the member's benefit plan.

Private rooms are reimbursed at the contractual semi-private room rate.

Not Reimbursed (examples)

Experimental, investigational, and/or cosmetic services are not reimbursed; authorization of an admission does not override these coverage limitations.
Services associated with Serious Reportable Events (SRE), 'never events', and provider preventable conditions (PPC) are not reimbursed; SREs recognized include those identified by NQF and CMS HAC/POA reporting.
Claims reimbursed based on APR-DRG and MS-DRG methodology are not eligible for interim billing or late charges.

Present on Admission (POA) indicator is required for each diagnosis when applicable and must follow CMS definitions; submit claims electronically using the industry-standard 837I ANSI format with appropriate bill type and segments.

If the submitted DRG differs from the system-assigned DRG, Mass General Brigham Health Plan's assigned DRG takes precedence; providers may appeal with supporting medical records.

Provider payment criteria

Payment is subject to member eligibility and benefits, provider contract terms, and applicable authorization and utilization management.

Member eligibility and applicable benefit coverage on the date of service must be met for payment; coordination of benefits applies where appropriate.

Payment and reimbursement are governed by the provider's contract with Mass General Brigham Health Plan; in the event of conflict, the provider agreement terms prevail.

Claims are processed using DRG methodologies (including MS-DRG for Medicare Advantage) and industry-standard procedure code edits and coding conventions; providers must reference current CPT, HCPCS Level II, and ICD-10-CM manuals for code reporting.

Various services and procedures require referral and/or authorization per the member's benefit plan; authorization, referral, notification, and utilization management requirements must be met when applicable for claim payment.

Claims are subject to payment edits, claims editing logic, and audit; adherence to plan policies, coding conventions, and requisite modifier usage is required and may affect payment or denial.

Required Codes, DRG & Claim Elements

Required code sets and elementsmixed

ICD-10-CM	Diagnosis and procedure codes used for DRG assignment and claim submission
CPT/HCPCS	Procedure codes to be referenced from current CPT and HCPCS Level II manuals

DRG codingmixedCovered

MS-DRG

Medicare Severity Diagnosis Related Groups referenced for Medicare Advantage reimbursement

inv-05: Minimum DRG claim elements

Required diagnosis and procedure codesICD-CM diagnosis codes and ICD-CM procedure codes must be submitted for DRG assignment

Patient demographicsDate of Birth and Gender must be included on the claim

Episode and disposition dates/statusAdmit Date, Discharge Date, and Status of Discharge are required

Clinical detail when applicableBirthweight (when applicable) and Days on Mechanical Ventilator (value or ICD-10-CM code) must be reported

Most actionable requirementClaims submitted for DRG payment must contain all minimum DRG elements (diagnosis/procedure codes, DOB, gender, admit/discharge dates, discharge status) to ensure accurate grouping and payment

Authorization, Eligibility & Billing Actions for Providers

Prior Authorization

Prior authorization required for inpatient admissions (except routine newborn delivery)

Authorization is required for all inpatient services except routine newborn delivery. Various services and procedures may also require referral and/or authorization per the member's benefit plan; providers must follow the referral and authorization requirements applicable to the member.

Obtain prior authorization for inpatient admissions except routine newborn delivery.
Check member-specific referral/authorization rules before providing services.

Documentation Required

Verify eligibility, benefits, and required authorizations for payment

Claims payment depends on member eligibility and the member's benefit coverage on the date of service, coordination of benefits, applicable referral/authorization/notification and utilization management rules, adherence to plan policies and claims editing logic, and the provider contractual agreement.

Key Terms and Billing Definitions

inv-09: Inpatient Hospital Admissions

DefinitionInpatient Hospital Admissions include items and services furnished to an inpatient, including room and board, nursing care and related services, diagnostic and therapeutic services and medical and surgical services.

Room and board coverage noteRoom and board charges are part of inpatient services; contractual semi-private room rate applies per provider agreement

Included clinical and ancillary servicesDiagnostic, therapeutic, medical and surgical services provided during the inpatient stay are included as inpatient services

inv-10: Present on Admission (POA)

Y / 1Present at the time of inpatient admission (POA).

N / 1Not present at the time of admission (POA).

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Payment Guidelines

Policy CodePolicy N/A

Change TypeDocument restructureMS-DRG incorporation

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for all inpatient services except routine newborn delivery per the member's benefit plan.

SourceLink

On This Page

inv-06: Claims editing and coding conventions

Industry-standard editsClaims are processed using industry-standard procedure code edits and coding conventions

DRG software processingMass General Brigham Health Plan processes DRG claims through DRG software which assigns the plan DRG

Precedence and appealsIf submitted DRG differs from system-assigned DRG, the plan-assigned DRG takes precedence; providers may appeal with medical record documentation

Payment determinersPayment is subject to member eligibility/benefits, coordination of benefits, referral/authorization/notification, utilization management, and provider contract terms

Verify member eligibility and applicable benefits for the date of service before billing.
Ensure required referrals, authorizations, or notifications are obtained and documented to support payment.
Follow plan policies, claims editing logic, and provider contract terms; contract terms prevail if conflicts exist.

U / 1Documentation is insufficient to determine if condition is present on admission (POA).

W / 1Clinically undetermined; provider is unable to clinically determine whether condition was present or not on admission (POA).

inv-11: DRG billing guidelines

DRG methodologiesAPR-DRG used for Commercial and Medicaid members; MS-DRG used for Medicare Advantage (MS-DRG incorporates POA into assignment).

DRG submission requirementDRG-contracted facilities must submit claims with DRG coding; claims lacking sufficient data for grouping will be rejected and returned.

System precedence and appealsIf submitted DRG and system-assigned DRG differ, the plan-assigned DRG takes precedence; providers may appeal with medical records to support ICD-10-CM principal/secondary diagnoses and/or ICD-10-PCS procedure codes.

Processing mechanicsDRG claims are processed through DRG software; accurate grouping depends on submission of the minimum coding and demographic elements.