Disclaimer

These reimbursement policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement if Blue Cross and Blue Shield of North Carolina (Blue Cross NC) Medicare Advantage covered the service for the Healthy Blue + MedicareSM (HMO-POS D-SNP) member's benefit plan.

The determination that a service, procedure, item, etc. is covered under a member’s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence.

You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be billed with Current Procedure Terminology^® (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, and/or revenue codes. These codes denote the services and/or procedures performed and, when billed, must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our reimbursement policies apply to both participating and non-participating professional providers and facilities.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, Blue Cross NC Medicare Advantage may:

• Reject or deny the claim. 
• Recover and/or recoup claim payment. 
• Adjust the reimbursement to reflect the appropriate services and/or procedures performed. 

These reimbursement policies may be superseded by mandates in provider, state, federal, or Centers for Medicare & Medicaid Services (CMS) contracts and/or requirements. Blue Cross NC Medicare Advantage strives to minimize delays in policy implementation. If there is a delay, we reserve the right to recoup and/or recover claims payment to the effective date in accordance with the policy. We reserve the right to review and revise these policies when necessary. When there is an update, we will publish the most current policy to the website. 

Policy

Blue Cross NC Medicare Advantage allows reimbursement for applicable services prior to admission to an inpatient hospital (referred to as the payment window) unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement is based on CMS guidance as follows:

• For the following hospitals, preadmission services are included in the inpatient reimbursement for 24 hours prior to and including the day of the member’s admission, and therefore, are not separately reimbursable expenses: 
  • Admitting hospitals
    
    Note: This includes any entity wholly owned or wholly operated by the admitting hospital or by another entity under arrangements with the admitting hospital. 
  • Psychiatric hospitals and units 
  • Inpatient rehabilitation facilities and units 
  • Long-term care hospitals 
  • Children’s hospitals 
  • Cancer hospitals 
• For Critical Access Hospitals (CAHs), preadmission services are not subject to the one (1) day payment window and, therefore, are separately reimbursable expenses from the inpatient stay reimbursement. 
• The one-day payment window does not apply to preadmission services included in the rural health clinic (RHC) or federally qualified health center (FQHC) all-inclusive rate.

Preadmission Services

Preadmission services are included in the inpatient reimbursement and consist of all diagnostic outpatient services and admission-related outpatient nondiagnostic services.

A hospital may attest to specific nondiagnostic services as being unrelated by adding a condition code 51 to the outpatient nondiagnostic service to be billed separately. Providers should append Modifier PD to diagnostic and nondiagnostic services that are subject to the preadmission payment window.

Outside Payment Window

Blue Cross NC Medicare Advantage does not consider the following services to be included in the payment window prior to an inpatient stay for preadmission services: 

• Ambulance services 
• Maintenance renal dialysis services 
• Services provided by: 
  • Skilled nursing facilities 
  • Home health agencies 
  • Hospices 
• Unrelated nondiagnostic services  

Note: These services may be considered for separate outpatient reimbursement. 

Related Coding

Standard correct coding applies  

Policy History 

Policy Section: Facilities 

Policy Number: G-01017 

12/11/2023 Review approved and effective: no changes

01/01/2021 Initial approval and effective  

References and Research Materials

This policy has been developed through consideration of the following:

• CMS 
• State contract  

Definitions

Admission-Related Outpatient Nondiagnostic Services: Services that are furnished in connection with the principal diagnosis assigned to the inpatient admission

Condition Code 51: Denotes attestation of Unrelated Outpatient Non-Diagnostic Services

Modifier PD: Indicates that the service is related to the inpatient admission 

Related Policies and Materials

Modifier Usage

Transportation Services: Ambulance and Non-Emergent Transport