CurrentMolina HealthcarePolicy N/A

Inpatient hospital room accommodation reimbursement (semi-private vs private)

Defines Molina Healthcare's reimbursement rules for inpatient hospital accommodations, specifying when private room charges are covered and billing requirements for hospitals; applies to Molina providers and claims processing.

Policy Summary

PayerMolina Healthcare

PolicyInpatient hospital room accommodation reimbursement (semi-private vs private)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse revenue code 0110 for private room charges and include condition code 38 or 39 or value code 02 as applicable; include private-minus-semi-private differential in remarks when patient requests private room without medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3circumstances private room charges are covered

0110primary revenue code

38,39condition codes referenced

02value code for facility-only private rooms

Private vs Semi-Private Room Coverage

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Private room coverage criteria

Molina will pay the same amount for routine inpatient accommodations regardless of room type; private room charges are covered only under specific conditions:

Private Room as the Only Option: Private room is covered when a private room is the only available option and the hospital stay is medically necessary.

Required documentation: condition code 38 or facility documentation showing no semi-private availability.

Facility with Only Private Accommodations: Private room is covered when the facility exclusively offers private accommodations.

Required documentation: include value code 02 with amount $0.00 on the claim.

Billing and Claim Submission Requirements: Use revenue code 0110 for private room charges and include the appropriate condition or value codes as applicable.

Include condition code 39 for medically necessary private room, condition code 38 when semi‑private not available, or value code 02 for facilities with only private rooms; ensure required remarks for non‑medically necessary differentials are present.

Billing Codes and Coding Requirements

Private room billing codesmixedCovered

0110	Room and board - private room
38	Semi-private room not available (condition code)
39	Private room medically necessary (condition code)
02	Hospital has no semi-private rooms (value code, amount $0.00)

Private room differential requirement

Required remark contentClaims for non-medically necessary private room rates must include remarks showing the private room rate minus the semi-private room rate (example: $500 - $400 = $100).

Differential calculationShow private-minus-semi-private rate (private rate less semi-private rate) as the private room differential on the claim remarks.

Customary difference limitDifferential should not exceed the customary difference at time of admission (per policy guidance).

Return of incomplete claimsClaims missing the required differential calculation in remarks will be returned to the provider.

Revenue and code usage noteUse revenue code 0110 for private room charges; non-medically necessary private rooms should not include condition or value codes on the claim.

Billing and Claim Submission Actions

Billing Rule

Billing and claim submission actions for private rooms

Use revenue code 0110 for all private room charges. For medically necessary private rooms, include the applicable condition code (38 when a semi-private room is not available; 39 when a private room is medically necessary). For non‑medically necessary private rooms, include in the claim remarks the private-minus-semi‑private differential (showing calculation, e.g., $500 - $400 = $100); claims lacking this remark will be returned. For facilities that only offer private rooms, include value code 02 with an amount of $0.00.

Revenue code 0110 must be used for private room billing.
Include condition code 38 or 39 for medically necessary private rooms as applicable.
For elective/non‑medically necessary private rooms, include remarks showing private rate minus semi‑private rate; missing remarks will cause claims to be returned.
If facility has only private rooms, include value code 02 with $0.00.