CurrentUnitedHealthcarePolicy PCA-1-23-04151-Clinical-FAQ_12212023

UnitedHealthcare Medicare Advantage hospital services review process

Defines UnitedHealthcare Medicare Advantage approach to inpatient hospital admission review effective Jan 1, 2024, including applicability of the two-midnight benchmark/presumption, use of medical necessity criteria, case-by-case exceptions, and reliance on CMS rules, InterQual, and internal coverage summaries for determinations.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Medicare Advantage hospital services review process

Policy CodePolicy PCA-1-23-04151-Clinical-FAQ_12212023

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionInclude documentation of the admitting physician's reasonable expectation that the stay would cross two midnights and, if it did not, the reason why.

POLICY UPDATE CHANGES

No material clinical/coverage changes.

FollowsTwo-midnight benchmark

Not followedTwo-midnight presumption

Med dir reviewCase-by-case exception

Follows IPO listInpatient-only procedures

Coverage Summary

Scope: UnitedHealthcare Medicare Advantage approach to inpatient hospital admission review effective 2024-01-01. This policy defines applicability of the two-midnight benchmark/presumption, use of medical necessity criteria, case-by-case exceptions, and reliance on CMS rules, InterQual, and UnitedHealthcare internal coverage summaries for determinations. Policy number: PCA-1-23-04151-Clinical-FAQ_12212023. Payer: UnitedHealthcare Medicare Advantage.

PayerUnitedHealthcare

PolicyUnitedHealthcare Medicare Advantage hospital services review process

Policy NumberPCA-1-23-04151-Clinical-FAQ_12212023

Effective Date2024-01-01

Last Review2023-12-21

StatusCURRENT

Key highlights:

- Follows two-midnight benchmark: UnitedHealthcare complies with the two-midnight benchmark in 42 CFR 412.3(d)(1).

- Does not follow two-midnight presumption: The Medicare FFS two-midnight presumption does not apply to Medicare Advantage plans and is not followed.

- Case-by-case exception requires medical director review: Admissions not expected to cross two midnights may be reviewed under a case-by-case pathway requiring clinical judgment by a UnitedHealthcare medical director.

- Follows CMS IPO list: UnitedHealthcare follows CMS’s Inpatient-Only (IPO) list; medically necessary inpatient-only procedures meet inpatient criteria regardless of length of stay.

Medical-Necessity Criteria

General inpatient admission medical necessity

Inpatient admissions are covered when ALL of the following are met:

ALL of the following

Hospital services are reasonable and necessary to be covered at the inpatient level
All hospital services must be reasonable and necessary to be covered at the inpatient level; custodial or convenience care is not appropriate for inpatient coverage (see documentation of complex medical factors).
Medical record documents complex medical factors that support the admitting physician's reasonable expectation that the patient requires hospital care that will cross 2 midnights
Reviewers will apply UnitedHealthcare Medicare Advantage coverage summaries, UnitedHealthcare Commercial Hospital Services: Observation and Inpatient medical policy and InterQual criteria as sources of medical evidence.
Hospital care is not custodial, for convenience, or not required for diagnosis or treatment of illness or injury
Custodial or convenience care is not appropriate for inpatient coverage.
Time counted toward two-midnight benchmark excludes any extensive delays in provision of medically necessary services
Document any extensive delays; such delays are excluded from time counted toward the two-midnight benchmark.

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Two-midnight benchmark and presumption

Policy statements regarding two-midnight rules:

ALL of the following

UnitedHealthcare follows the two-midnight benchmark (42 CFR 412.3(d)(1)) as a payment criterion
UnitedHealthcare complies with payment criteria for inpatient admissions at 42 CFR 412.3, including the two-midnight benchmark.
UnitedHealthcare does NOT apply the two-midnight presumption used by Medicare FFS medical review contractors; the presumption does not apply to Medicare Advantage plans
CMS has confirmed the two-midnight presumption does not apply to Medicare Advantage plans.

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Stays under 24 hours / short stays

Short-stay considerations:

ALL of the following

ONE of
- unexpected death
- unexpected discharge against medical advice
- unexpected transfer
- unexpected hospice
- unexpected rapid improvement

Case-by-case exception

Case-by-case exception applies when member was not expected to require care crossing 2 midnights:

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Inpatient-only procedures

IPO list rule:

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Provider Actions & Requirements

Documentation Required

Document physician expectation for two-midnight stay

Include documentation of the admitting physician's reasonable expectation that the stay would cross two midnights and, if it did not, the reason why (required for cases with less than two midnights). Document complex medical factors supporting the admitting physician's expectation (for example: history/comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event).

Prior Authorization

Case-by-case medical director review

Admissions not expected to cross two midnights may be reviewed under the case-by-case exception by a UnitedHealthcare medical director who will evaluate the admitting physician's decision based on documented complex medical factors (including, but not limited to, history and comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event).

Documentation Required

Avoid counting delays toward two-midnight benchmark

Do not include extensive delays in provision of medically necessary services when calculating time toward the two-midnight benchmark; document any such delays in the medical record so they are excluded from time counted toward the benchmark.

Reviewer guidance for evidence sources: UnitedHealthcare reviewers will apply the Hospital, Emergency and Ambulance Services Medicare Advantage Coverage Summary, the UnitedHealthcare Commercial Hospital Services: Observation and Inpatient medical policy, and InterQual criteria as sources of medical evidence when evaluating whether documented complex medical factors support the admitting physician’s reasonable expectation that inpatient care crossing two midnights is necessary.

Definitions & FAQs

Background/overview: UnitedHealthcare Medicare Advantage aligns with applicable Original Medicare laws for inpatient payment criteria but may adopt internal coverage criteria when Original Medicare statutes, regulations, NCDs or LCDs do not provide fully determinative criteria. InterQual may be used as a source of medical evidence to create and support UnitedHealthcare’s internal coverage summaries and medical necessity determinations.

Definitions:

- Two-midnight benchmark: A payment criterion (42 CFR 412.3(d)(1)) where inpatient stays expected to span at least two midnights are considered when determining inpatient payment.

- Two-midnight presumption: A Medicare FFS medical review instruction presuming stays crossing two midnights are appropriate for payment; this presumption does not apply to Medicare Advantage plans.

- Case-by-case exception: A review pathway where inpatient payment may be considered for admissions not expected to cross two midnights based on the clinical judgment of a UnitedHealthcare medical director and documented complex medical factors.

- Inpatient-only (IPO) list: CMS’s list of procedures that require inpatient status when performed; UnitedHealthcare follows this list for inpatient admission determinations.

Question	Answer
Does UnitedHealthcare follow CMS's Inpatient Only list?
Yes; medically necessary inpatient-only procedures meet criteria for inpatient admission regardless of length of stay.

42 CFR 412.3(d)(1)	Payment criteria for inpatient admissions including two-midnight benchmark
42 CFR 412.3(d)(3)	Related inpatient payment regulation citation referenced in resources
NCD 70.5	National Coverage Determination for Hospital and Skilled Nursing Facility Admission Diagnostic Procedures
88 Fed. Reg. 22120; 22191-22195 (Apr. 12, 2023)	CMS Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program references

OpenPayer

UnitedHealthcare Medicare Advantage hospital services review process

Coverage Summary

Medical-Necessity Criteria

Provider Actions & Requirements

Regulatory & Reference Citations

Definitions & FAQs

Medicare Determinations

Revision History

Name	Number	Type	Effective Date
Hospital and Skilled Nursing Facility Admission Diagnostic Procedures
70.5
NCD