CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Inpatient Facility Services — Reimbursement and Payment Policy

Governs reimbursement and payment methodologies for inpatient hospital admissions and related facility services for Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInpatient Facility Services — Reimbursement and Payment Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and authorization requirements; contact Provider Services for questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursminimum inpatient stay length (stays under billed as outpatient)

inclusiveinpatient rate inclusive of ancillary and facility services

MS-DRG / PPSpayment methodology (INTEGRITY/Commercial)

FFSprofessional claims reimbursement

up to 3 dayspre-admission services included

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Inpatient Coverage & Payment Criteria

Inpatient coverage criteria

Coverage and payment for inpatient admissions are provided when the following criteria and payment rules are met.

All services must be medically necessary to qualify for reimbursement; Neighborhood may reference National Coverage Determination (NCD), Local Coverage Determination (LCD), InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies (CMP) when determining medical necessity.

Providers are responsible for verifying member eligibility, coverage and authorization criteria prior to rendering services; contact Provider Services for questions.

Professional inpatient claims are reimbursed Fee-For-Service for all lines of business.

ALL of the following

Line of business rules (choose applicable)
- Medicaid: reimbursement in accordance with the provider’s contract terms.
- INTEGRITY and Commercial: reimbursement per CMS Inpatient Prospective Payment System (PPS) using Medicare Severity Diagnosis Related Groups (MS-DRG).

Outpatient and pre-diagnostic services provided up to three (3) days prior to an inpatient admission are considered part of the MS-DRG payment and are not reimbursed separately when applicable.

Inpatient reimbursement is inclusive of facility-provided services (not reimbursed separately) including, but not limited to: ancillary services, anesthesia care, appliances/equipment, blood administration, bedside equipment, diagnostic services, medications and supplies, laboratory services, nursing care, pathology services, operating room services, preadmission testing (covered but not reimbursed separately), recovery room services, radiology/imaging services, and therapeutic items (drugs and biologicals).

Eligibility changes during a stay: If a member has another insurer at admission and later becomes eligible with Neighborhood during the stay, the other insurer is responsible for the entirety of the stay. Neighborhood will reimburse until care is formally transferred to another plan or, if no transition occurs, through the end of the admission. Providers must bill per the member’s eligibility dates (use statement from / through dates corresponding to eligibility).

Exclusions: services payable as outpatient, nursing facility services furnished as Medicaid swing-bed services, post-hospital SNF care furnished by hospitals with bed approval, and hospital inpatient stays under 24 hours (these must be billed as outpatient) are excluded from inpatient coverage under this policy.

Documentation and claims: Providers must submit complete UB-04 claims using required coding systems; Neighborhood may request medical records and documentation must support billed services and medical necessity. Claims are subject to contractual timely filing and program/payment rules.

Coding, Timely Filing & Systems

Required coding systemsmixed

ICD-10-CM, CPT, HCPCS

Coding systems referenced for claim submission and definitions.

Timely filing

Timely filing requirementSubmit complete claims for payment within contractually determined timely guidelines per provider contract; refer to Provider Manual for UB-04 required fields.

Required claim formUB-04 with required fields as detailed in the Provider Manual.

Coding standardsClaims must meet CPT, ICD-10-CM, and HCPCS Level II coding standards per AMA and coding manuals.

Provider Responsibilities & Documentation

Prior Authorization

Eligibility & Authorization Responsibility

It is the provider's responsibility to verify member eligibility, benefit coverage, and obtain any required prior authorization before rendering services. Contact Provider Services at 1-800-963-1001 with questions about eligibility, coverage, or authorization requirements. Providers should also consult Neighborhood’s Clinical Medical Policies and any applicable NCDs, LCDs, InterQual criteria, and Rhode Island EOHHS guidance when determining medical necessity.

Verify eligibility and benefits prior to scheduling or providing services.
Obtain and document all required prior authorizations before service delivery.
Refer to Neighborhood Clinical Medical Policies and applicable coverage determinations for authorization criteria.

Documentation Required

Medical Record Documentation

Neighborhood reserves the right to request medical records for any service billed. Medical record documentation must clearly support the services billed and the medical necessity of those services. Documentation should meet CMS standards for proper medical record content, including but not limited to: reason for visit, history, physical exam, diagnoses, treatment plan, informed consent (when applicable), and contemporaneous provider signatures and dates.

Key Terms & Rate Inclusions

Inpatient care

DefinitionInpatient care: any medical service that requires admission into a hospital.

Policy scopeApplies to inpatient facility services governed by this policy for reimbursement and payment.

Documentation expectationServices must be supported by medical record documentation (Neighborhood may request records to support billed services).

Inpatient rate inclusions

Inclusive rate statementThe inpatient reimbursement rate is inclusive of all services provided by the facility (see list).

Examples of included servicesAncillary services; anesthesia care; appliances and equipment; blood administration; bedside equipment; diagnostic services; medication and supplies; laboratory services; nursing care; pathology services; operating room services; recovery room services; radiology/imaging services; therapeutic items (drugs and biologicals).