CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Inpatient facility services reimbursement

Governs coverage and reimbursement requirements for inpatient hospital facility services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business; affects providers submitting inpatient claims.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInpatient facility services reimbursement

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage and authorization criteria prior to rendering services and refer to Neighborhood's Prior Authorization Reference page or contact Provider Services at 1-800-963-1001.

SourceLink

POLICY UPDATE CHANGES

09/18/2024 Annual Review Date noted with no content changes.

Medicaid, INTEGRITY, CommercialLines of business covered

Anesthesia, lab, radiologyIncluded services examples

MS-DRG / CMS PPSPayment methodology

24 hoursMinimum inpatient stay

Inpatient Coverage Criteria

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Inpatient coverage criteria and exclusions

Coverage is provided when services are medically necessary and meet applicable Plan criteria (including LCD/NCD), InterQual, and Neighborhood Clinical Medical Policies. Documentation must support billed services and medical necessity. Certain services are excluded as noted.

All services must be medically necessary to qualify for reimbursement.

Medical necessity may be determined using the following:

Local Coverage Determination (LCD).
National Coverage Determination (NCD).
InterQual criteria.
Neighborhood Clinical Medical Policies (CMP).

Providers are responsible for verifying eligibility, coverage, and any authorization requirements prior to rendering services; see Neighborhood's Prior Authorization Reference and Clinical Medical Policies or contact Provider Services at 1-800-963-1001.

Documentation in the medical record must support the service(s) billed and demonstrate medical necessity. Neighborhood may request medical records and follows CMS standards for documentation requirements.

Inclusions (payment scope):

Inpatient reimbursement is based on the applicable contracted rate (e.g., DRG/MS‑DRG) and the facility rate is inclusive of services such as anesthesia, ancillary services, appliances/equipment, blood administration, bedside equipment, diagnostic services, medications and supplies, laboratory services, nursing care, pathology services, operating room services, preadmission testing, recovery room services, radiology/imaging, and therapeutic items (drugs and biologicals).

Inpatient-only procedures:

Neighborhood will follow CMS guidance for inpatient-only procedures as listed in Medicare's inpatient-only lists/OPPS Addenda; such procedures are expected to be performed in the inpatient setting.

Minimum stay and billing exceptions:

Hospital inpatient stays must be at least 24 hours; stays less than 24 hours must be billed as outpatient.

Exclusions (not covered under this inpatient policy):

Services considered payable as outpatient services.
Nursing facility services furnished in a hospital bed that is approved to furnish nursing facility services (swing‑bed situations) where applicable.
Post‑hospital SNF care furnished by a hospital or critical access hospital that has a bed approval (swing‑bed) when applicable.

Refer to the provider's contract for any contract provisions that may supersede this policy regarding inpatient reimbursement.

Coding and Billing Rules

Required code sets for claim submissionmixed

ICD-10-CM	Diagnosis coding required per policy
CPT	Procedure coding per AMA CPT codebook
HCPCS	HCPCS Level II coding for applicable services

Outpatient-to-inpatient pre-diagnostic window

Outpatient-to-inpatient pre-diagnostic windowOutpatient and pre-diagnostic services provided up to 3 days prior to an inpatient admission are considered part of the MS-DRG payment.

Applies toINTEGRITY and Commercial lines using CMS PPS / MS-DRG methodology.

Implication for billingServices within the 3-day window should not be billed separately from the inpatient MS-DRG payment.

Provider Requirements and Prior Authorization

Prior Authorization

Pre-service verification and prior authorization

It is the provider's responsibility to verify member eligibility, coverage and any authorization requirements prior to rendering inpatient services. Providers should consult Neighborhood's Prior Authorization Reference page and applicable Clinical Medical Policies, and may contact Provider Services at 1-800-963-1001 with questions.

Verify member eligibility and coverage before service delivery.
Confirm whether prior authorization is required via Neighborhood's Prior Authorization Reference page.
Reference applicable Clinical Medical Policies for coverage criteria.
Contact Provider Services at 1-800-963-1001 for policy questions.

Definitions — Inpatient Services

Inpatient care and inclusive facility services

DefinitionInpatient care: medical services that require admission to a hospital.

Inpatient reimbursement rate includesAnesthesia care; ancillary services; appliances and equipment; blood administration; bedside equipment; diagnostic services; medications and supplies; laboratory services; nursing care; pathology services; operating room services; preadmission testing; recovery room services; radiology/imaging services; therapeutic items (drugs and biologicals).

Contract precedenceApplicable network contracted rates (e.g., DRG) and provider contract terms may supersede this policy.

Preadmission testingRoutine preadmission testing performed prior to an admission is considered a covered service but is not reimbursed separately from the inpatient rate.