CurrentMass General Brigham Health PlanPolicy N/A

Provider Payment Guidelines — Inpatient Hospital Payment/Reimbursement

Governs reimbursement rules and billing requirements for inpatient hospital services provided to Mass General Brigham Health Plan members, affecting participating hospital facilities and their claims submission.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Payment Guidelines — Inpatient Hospital Payment/Reimbursement

Policy CodePolicy N/A

Change TypeOperational wording and reference updates (non-material)

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization/referral when required; all inpatient services require authorization except routine newborn delivery.

SourceLink

POLICY UPDATE CHANGES

Removed 'only when prior authorized under medical necessity' language.

Document restructure and added DRG billing guidelines and MS-DRG's for Medicare Advantage over prior versions.

Annual review entries indicating updates to links and references (MassHealth DRG, Acute Carve-Out Drug).

POA requiredPOA requirement

APR-DRG, MS-DRGDRG methods

Routine newbornAuthorization exception

2014-2026

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9Publication history items

Inpatient Coverage and Billing Rules

Inpatient coverage and billing criteria

Rules governing what is reimbursed, exclusions, and special billing arrangements.

ALL of the following

Mass General Brigham Health Plan reimburses medically necessary inpatient services provided to participating hospital facilities per contracted rates and member benefit plans; claims are subject to payment edits and review for eligibility for payment.
Inpatient acute medical admissions are reimbursed when the plan is notified within appropriate timeframes.

ALL of the following

Services reimbursed based on APR-DRG or MS-DRG methodology are not eligible for interim billing or late charges.
Private rooms are reimbursed at the contractual semi-private room rate (separate private room reimbursement will not be made).
Experimental, investigational, and/or cosmetic services are not reimbursed; prior authorization for an inpatient admission does not override these coverage limitations.
Services associated with Serious Reportable Events (SRE), 'never events', and provider preventable conditions (PPC) are not reimbursed; SRE/PPC are recognized per National Quality Forum and CMS HAC definitions and require correct industry-standard coding and POA indicators when applicable.

ALL of the following

If a patient transfers from the emergency department or observation status to inpatient, separate reimbursement will not be made for ER charges or observation bed hours.
Room and board represent a full 24-hour calendar day for reimbursement purposes.

ALL of the following

DRG-contracted hospitals must submit required DRG coding and the minimum discharge data elements; DRG software is used for grouping and the plan-assigned DRG prevails when it differs from the submitted DRG.
Claims that cannot be grouped due to insufficient data will be rejected; submit claims electronically using the correct industry-standard formats and include POA indicators for each diagnosis code when applicable.

ALL of the following

Delivery is billed under the mother's member ID and nursery services under the newborn's member ID.
Routine nursery charges are covered but not reimbursed separately for the Mass General Brigham Health Plan commercial line of business.

ALL of the following

APR-DRG per diem conversion: Base Rate * APR-DRG weight / Network Average Length of Stay.
MS-DRG per diem conversion: Base Rate * MS-DRG weight / Geometric Mean Length of Stay.
Transfer per diem conversion: Observed length of stay (LOS) for transfer case multiplied by the calculated per diem conversion; final payment is the lesser of the per diem or acute reimbursement.

Provider payment conditions

High-level coverage stance and limitations

ALL of the following

Claims payment is contingent on the member's eligibility and benefits on the date of service.

ALL of the following

Payment is subject to coordination of benefits when applicable.

ALL of the following

Referral, authorization, notification, and utilization management guidelines apply when applicable; various services and procedures require referral and/or authorization.
Authorization is required for inpatient services except routine newborn delivery (authorization requirements located in referenced provider resources).

Coding, DRG Guidance, and Discharge Data Requirements

Required coding systemsmixed

ICD-10-CM	Diagnosis and procedure coding for DRG assignment and claims
CPT	Procedure coding as referenced for reporting services
HCPCS	HCPCS Level II codes as referenced

DRG / MS-DRG guidancemixed

MS-DRG

Incorporated MS-DRG's for Medicare Advantage and DRG billing guidelines referenced

Minimum discharge data elements

ICD diagnosis and procedure codesICD-CM diagnosis codes and ICD-CM procedure codes are required for APR-DRG and MS-DRG assignment

Patient demographicsDate of Birth and Gender must be submitted on discharge records

Birthweight (when applicable)Birthweight is required when applicable for neonatal/subclass assignment

Admission and discharge timingAdmit Date and Discharge Date must be provided for each inpatient discharge

Disposition and ventilator dataStatus of Discharge and Days on Mechanical Ventilator (value or ICD-10-CM code) must be included

Authorization, Eligibility, and Submission Requirements

Prior Authorization

Authorization requirements

Referral and/or prior authorization is required for various services; authorization is required for all inpatient services except routine newborn delivery.

Providers must check referral and authorization requirements (links referenced in policy) before submitting claims.
Authorization remains required for all inpatient services with the sole exception of routine newborn delivery.

Documentation Required

Authorization and eligibility considerations

Claims payment is contingent on the member's eligibility and benefits on the date of service and is subject to coordination of benefits, applicable referral/authorization/notification and utilization management rules, claims editing logic, plan policies, and the provider contract.

Adhere to applicable referral/authorization/notification and utilization management guidelines when applicable.

Key Definitions and Indicators

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 & boardRoom and board represent full 24-hour calendar day and are included in inpatient admission reimbursement per contracted rates

Nursing and related servicesNursing care and related services are included as part of inpatient hospital admissions

Diagnostic and therapeutic servicesDiagnostic and therapeutic services provided during the inpatient stay are included in the admission definition

Present on Admission (POA) indicator

Y (Present on Admission)

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Payment Guidelines — Inpatient Hospital Payment/Reimbursement

Policy CodePolicy N/A

Change TypeOperational wording and reference updates (non-material)

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization/referral when required; all inpatient services require authorization except routine newborn delivery.

SourceLink

On This Page

ALL of the following

Claims are subject to claims editing logic, plan policies and procedures, and provider contractual agreement.
In the event of a conflict between this payment guideline and the provider's agreement, the provider's agreement terms and conditions prevail.

ALL of the following

Providers must report procedure and diagnosis codes using current CPT, HCPCS Level II, and ICD-10-CM manuals; CMS or CPT guidelines should be followed for modifier usage as absence or presence of a modifier may affect payment or denial.

Publication history updates

July 1, 2014Original documentation; document structure established

January 1, 2019 - January 1, 2024Document restructure with codes, code descriptor and references updated; rebrand and incorporation of MS-DRG's for Medicare Advantage

January 1, 2025 - May 8, 2026Annual reviews; added MassHealth links and operational wording removal noted in 2026 publication history

Multiple listed dates (2014–2026)Publication history shows successive updates to codes, descriptors, DRG guidance, and references across listed dates

Provider contract terms and conditions prevail in the event of a conflict with this payment guideline.

Y, 1 = Present at the time of inpatient admission

N (Not present)N, 1 = Not present at the time of admission

U (Insufficient documentation)U, 1 = Documentation is insufficient to determine if condition is present on admission

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

Payment policy definition

Payment policy purposePayment policy determines the rationale by which a submitted claim for service is processed and paid

Factors consideredFormulation considers provider contract terms, member benefit scope, clinical rationale, industry-standard code edits, and coding conventions

Conditions on paymentClaims payment is subject to member eligibility/benefits on date of service, coordination of benefits, referral/authorization/notification and utilization management when applicable

Contract precedenceIf conflict exists between this guideline and the provider's agreement, the provider agreement terms and conditions prevail