CurrentMass General Brigham Health PlanPolicy N/A

Inpatient Hospital Facility Reimbursement Policy

Defines Mass General Brigham Health Plan's reimbursement rules and provider payment guidelines for medically necessary inpatient hospital services for participating hospital facilities and affected members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyInpatient Hospital Facility Reimbursement Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for all inpatient services except routine newborn delivery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

POA requiredPOA indicator required

RequiredAuthorization

APR-/MS-DRGDRG methodology

No separate payER/observation pay

Not reimbursedSRE/PPC

Coverage and Reimbursement Criteria

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COVERAGE CRITERIA

General coverage and reimbursement rules for inpatient services and exclusions.

Reimburses participating hospital facilities for medically necessary inpatient services in accordance with member benefit plans and provider contracts.

Providers are reimbursed according to the plan's network provider reimbursement or contracted rates; claims are subject to payment edits and member liability (e.g., copayments, deductibles, coinsurance) applied per the member's benefit plan.

All claims are subject to audit; medical records may be requested. Admission status must be by physician order and admission time is when inpatient care begins as documented in the medical record (the time an order is written or a bed held is not admission time).

When a patient transfers from the emergency room and/or observation status to inpatient status, separate reimbursement will not be made for emergency room charges or observation bed hours; room and board represents a full 24‑hour calendar day.

Claims reimbursed based on APR‑DRG or MS‑DRG methodology are not eligible for interim billing or late charges.

Private rooms are not reimbursed except when prior authorized for medical necessity; when authorized, reimbursement will be at the contractual semi‑private room rate.

Experimental, investigational, and cosmetic services are not reimbursed; authorization for admission does not override these coverage limitations.

Services associated with Serious Reportable Events (SREs) or Provider Preventable Conditions are not reimbursed, per the plan's Serious Reportable Events Payment Policy.

Coding and DRG Requirements

Required coding elementsmixed

ICD-10-CM	Diagnosis codes used for DRG and discharge data elements
ICD-10-PCS	Procedure codes used for DRG assignment when applicable
CPT/HCPCS	Procedure and service coding as referenced for reporting

DRG discharge data elements (supporting codes)mixed

Date of Birth	Member DOB used for DRG assignment
Gender	Member gender used for DRG assignment
Birthweight	Birthweight when applicable used for DRG assignment
Admit Date	Admission date used for DRG assignment
Discharge Date	Discharge date used for DRG assignment
Status of Discharge	Discharge status used for DRG assignment
Days on Mechanical Ventilator	Ventilator days (value or ICD-10-CM code) used for DRG assignment

DRG grouping minimum data

Minimum required coding elements for DRG claimsClaims submitted for payment by DRG must contain the minimum requirements to ensure accurate claim payment (diagnosis and procedure coding and required discharge elements); insufficient data that prevents grouping will cause the claim to be rejected and returned.

DRG software and plan-assigned DRGMass General Brigham Health Plan processes DRG claims through DRG software; if the submitted DRG and system-aligned DRG differ, the Plan-assigned DRG will take precedence.

Appeals for DRG assignmentProviders may appeal the Plan-assigned DRG with medical record documentation to support the ICD-10-CM principal/secondary diagnoses and/or ICD-10-PCS procedure codes.

Consequence of insufficient dataIf the claim cannot be grouped due to insufficient data, it will be rejected and returned.

Authorization noteMass General Brigham Health Plan continues to require authorization for all inpatient services except routine newborn delivery.

Authorization, Notification, and Provider Responsibilities

Prior Authorization

Obtain authorization for inpatient services (except routine newborn delivery)

Authorization is required for all inpatient services except routine newborn delivery. Providers must follow plan links for additional referral or authorization requirements for specific services and procedures.

Obtain prior authorization for any inpatient admission unless the admission is a routine newborn delivery.
Check plan-specific referral/authorization links for procedures or services that may have additional requirements.

Prior Authorization

Notify plan of inpatient acute medical admissions

Inpatient acute medical admissions must be notified to Mass General Brigham Health Plan within the plan's required timeframes.

Notify the plan of inpatient acute medical admissions according to the plan's notification timelines to ensure eligibility for reimbursement.

Definitions and Indicator Values

Inpatient Hospital Admissions — included services

Scope of ‘Inpatient Hospital Admissions’Includes 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 boardRoom and board charges are included as part of inpatient hospital admission services.

Nursing and related servicesNursing care and related services provided to the inpatient are part of the admission.

Diagnostic and therapeutic servicesDiagnostic and therapeutic services furnished while an inpatient are included in the inpatient admission definition.

Medical and surgical servicesMedical and surgical services delivered during the inpatient stay are considered included services.

Present on Admission (POA) indicator values

POA = YPresent at the time of inpatient admission.

POA = NNot present at the time of inpatient admission.

POA = UDocumentation is insufficient to determine if the condition was present on admission.

POA = WClinically undetermined; provider is unable to clinically determine whether the condition was present on admission.