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Critical Access Hospital (CAH) Services
Hospital In-reach Service Coordination (IRSC)
Inpatient Hospital Authorization
Outpatient Hospital Services
All MHCP recipients are eligible to receive inpatient and outpatient hospital services.
A person residing in a correctional facility in Minnesota is eligible only for inpatient hospital services under MA.
An eligible facility, meeting the definition of and licensed as a hospital, is certified to participate in Medicare, including a hospital that is part of the Indian Health Service (IHS), and designated by the federal government to provide acute care.
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Professional services (for example, anesthesiologist and physician) are covered in addition to outpatient or inpatient hospital services. Other services, such as lab, radiology, supplies and injectable drugs may also be separately covered services when outpatient hospital services are provided. Refer to the specific service sections of this manual for coverage and billing policy.
Review information about the MHCP Pay-for-Performance Program.
Services provided in an outpatient or inpatient hospital setting are subject to the same requirements that apply to services by other providers, including:
See the Critical Access Hospital (CAH) Services section for billing instructions for critical access hospitals.
Copays apply to some services provided to MA recipients. Copay guidelines are listed in the Billing the Recipient section under Copays and Family Deductible.
Inpatient hospital services are covered if determined medically necessary (refer to Inpatient Hospital Authorization). Inpatient services provided by the same hospital on two separate patient care units by two medical services are billed as one continuous admission under MHCP. This includes patients transferred between acute general medical or surgical services to or from general psychiatric services. Do not follow Medicare billing guidelines for transfers between these services.
Inpatient admission for detoxification is covered when certain medical criteria are met (refer to Guidelines for Inpatient Hospital Detoxification). Inpatient hospitalization may be medically necessary due to conditions resulting from withdrawal or conditions occurring in addition to withdrawal and the conditions require constant availability of a physician and registered nurse or complex medical equipment found only in an inpatient hospital setting.
The medical records of recipients admitted for detoxification are subject to retrospective review by the medical review agent. Bill inpatient medical detoxification and treatment of sequelae resulting from drug or alcohol ingestion as any other acute inpatient admission. Do not use Basic Billing Instructions for Chemical Dependency Services designated for admissions covered under CCDTF.
Medical Assistance (MA) will cover inpatient hospital care for eligible people who are incarcerated and are then admitted to an inpatient hospital. Professional or dental service claims associated with the covered inpatient hospital stay are eligible for payment. Refer to the Outpatient Hospital Services Billing section for more information on billing these services.
Work with the correctional facility to complete the application process after the patient is discharged from an inpatient hospital stay. The correctional facility must initiate and facilitate the application process, help the incarcerated person to apply for MA, and provide all the necessary forms. MHCP has notified the Minnesota Department of Corrections and County Detention facilities of this process.
Effective for discharges on or after Jan. 1, 2016, when an incarcerated person presents at a hospital and is discharged on the same date, no room and board day will be allowed. For these stays, and all other outpatient stays, submit the charges incurred on the discharge day as outpatient claims via an outpatient claim form to the Department of Corrections or the responsible city or county correctional authority. Continue to bill the correctional facility for all outpatient services.
Medicare identifies procedures that should be performed only in an inpatient setting. MCHP follows Medicare guidelines for payment for inpatient-only procedures; we will pay for these procedures only on inpatient claims.
Medicaid Recipients with TPL
Follow the place of service rule of the primary payer. MHCP will not make payment if a provider does not follow the place of service rule of the primary payer.
The following inpatient hospital services are not covered:
MHCP recipient eligibility is generally approved on a monthly basis. If a recipient’s MHCP coverage ends during his or her inpatient stay, bill:
If the patient later becomes retroactively eligible for the entire inpatient stay, replace the claim, entering the Statement Covers Period dates as the entire inpatient stay.
If a recipient’s MHCP eligibility begins during an inpatient hospitalization and the person’s discharge date is not the same day as the admit date, use the following instructions for payment:
Effective for discharges on or after Jan 1, 2016, when a recipient is admitted to a hospital as an inpatient and the first day of eligibility is the discharge date, no room and board day will be allowed. For these stays, submit the charges incurred on the discharge day as an 837I outpatient claim. Do not claim reimbursement for service prior to eligibility.
Use the following instructions for payment:
Effective June 1, 2016, if a member changes health plans or changes from fee-for-service (FFS) to a health plan while he or she is in the hospital, the effective date of the health plan enrollment is no longer dependent on inpatient admit or discharge dates.
The previous health plan or FFS in effect at the time of admission remains financially responsible for the inpatient hospital services for that hospital stay and any related professional and ancillary services until discharge from the hospital.
The new health plan will be responsible for the services that are not related to the inpatient hospital stay beginning on the effective date of the enrollment. The same policy applies when a member changes from a health plan to FFS.
If a recipient’s MHCP coverage changes from FFS to managed care during a hospital stay, bill FFS for the entire stay.
If a recipient’s MCO coverage changes from MCO to FFS during a hospital stay, bill the MCO for the entire stay. Billing questions should be referred to the MCO.
If a recipient is admitted as an inpatient immediately following outpatient services (for example, emergency department, ambulatory surgery, radiology or observation status) at the same hospital, submit information in the following fields using these guidelines:
Include outpatient services provided immediately before an inpatient admission on the inpatient claim regardless of discharge date; however, the definition of covered days changed as of October 1, 2015.
Covered days are equivalent to the room and board days. Report covered days with value code 80 regardless of the date of discharge. Outpatient services were and continue to be included on the inpatient claim when outpatient services occur prior to admission.
Use the following information to report inpatient admission following outpatient services date for discharge date on or after October 1 2015:
When a recipient is admitted to a hospital as an inpatient and Inpatient Hospital Authorization (IHA) is denied, or the recipient does not meet inpatient criteria, MHCP may cover services provided in the hospital when billed as outpatient hospital services if the following apply:
If a trauma response team is activated, as described by the NUBC guidelines, and the hospital provides at least 30 minutes of critical care for which CPT code 99291 is reported, then:
If the hospital provides less than 30 minutes of critical care, you cannot report HCPCS G0390.
Do not submit inpatient hospital billing until the recipient is discharged. However, for lengths of stay over 30 days, hospitals may submit replacement claims each month after the initial bill incorporating the previously billed or paid stay. Interim bills must include Patient Discharge Status Code 30 (still an inpatient). If one or more interim payments have already been made, the payer claim number (PCN) of the claim being replaced must be included in the Original Reference Number field on the Claim Information tab in MN–ITS Interactive or in the REF02 Loop 2300 in MN–ITS Batch.
Split bills for inpatient stays that exceed 180 days; different payment rates will be applied to each part of the claim. The first 180 days, including the 180th day, will be paid at the normal DRG-based prospective payment system (PPS) rate, including any cost outlier payments, when applicable. Days 181 and beyond will be paid a standard fixed percentage of the charges associated with these days 181. Claims that are not split at day 180 will be denied.
Billing for days one through 180
Refer to the following when billing for days one through 180:
Billing for day 181 and beyond
The process for billing for days 181 and beyond can be done one of two ways:
For either of the two ways of billing:
Submit separate claims for a mother and her newborn. A newborn whose mother is enrolled in a health plan at the time of birth will be retroactively enrolled in the same health plan for the birth month, unless the newborn meets an exclusion. Refer to Prepaid Health Care Programs, Excluded Recipients section. Use admission Type ‘4’ only for the baby and only for the admission when the birth occurred. See Laboratory-Pathology Services for MDH Newborn Metabolic Disorder Screening.
With the implementation of the APR-DRG grouper on Oct. 1, 2015, MHCP now requires that all claims for babies less than 29 days old include a birth weight. MHCP will deny claims that do not contain a valid birth weight.
Include Value Code 54 (Newborn Birthweight in Grams) on all claims for babies under 29 days at time of admission. This is regardless of whether the baby was born inside or outside the hospital, and of whether the newborn was transferred to or from the hospital. If an ICD-10 diagnosis code indicating birth weight is reported on the claim, the birth weight must correlate to the weight reported with Value Code 54.
Submit separate claims for recipients with admissions to a Medicare designated rehabilitation unit using the rehabilitation unit’s NPI. The hospital must seek IHA for rehabilitation admissions. If a recipient is transferred between acute inpatient care and inpatient rehabilitation, each rehabilitation admission requires a different IHA number, unless the rehabilitation admissions are to be combined.
If the admissions to a Medicare designated rehabilitation unit are not issued separate IHA numbers by the medical review agent, indicate the days in the acute inpatient setting as leave of absence days. Similarly, if the admissions to acute inpatient do not meet criteria for separate payment (refer to Inpatient Hospital Authorization), indicate the days in the rehabilitation setting as leave of absence days.
For example, a recipient is admitted to an acute inpatient hospital, transferred to the rehabilitation distinct unit, readmitted into the acute inpatient hospital, and a few days later is readmitted into the inpatient rehabilitation unit.
If the admissions meet criteria for two acute inpatient payments, the provider must bill separate claims for each acute inpatient hospitalization with each hospital's NPI.
If the medical review agent did not issue a new IHA number for the second admission to the inpatient rehabilitation unit and the provider did not appeal the denial of a second IHA, the provider must submit one claim for both inpatient rehabilitation hospitalizations. The claim must indicate dates of the second acute inpatient hospitalization as leave days (refer to the NUBC website for the leave of absence span code), with its own IHA number, and with the hospital's inpatient rehabilitation NPI.
If an MA recipient has dual eligibility with Medicare, and exhausts Medicare benefits during an admission, the hospital can be paid the greater of the Medicare payment including deductible and coinsurance (Medicare beneficiary responsibility is paid by MA) or the MA payment less Medicare payment, including deductible and coinsurance. When Medicare Part A benefits are exhausted:
When recipients have a spenddown satisfaction date, inpatient claims must be submitted using the first date of eligibility (the spenddown satisfaction date) as the “from” date in the Statement Date field in MN–ITS Interactive or DTP Loop 2300 in MN–ITS Batch. The date of admission must contain the date of the recipient's admission to the inpatient hospital.
Hospitals must exclude certified registered nurse anesthetist (CRNA) charges from inpatient rates.
Bill separately on the 837P for MHCP-enrolled CRNA services provided in an inpatient hospital setting by any of the following:
Refer to the MN–ITS User Guide for more detailed information on billing for CRNAs who are employees or independent CRNAs. Remove CRNA costs from the operating payment rate for inpatient rates.
Bill inpatient hospital services provided to a MinnesotaCare enrollee to the enrollee’s health plan.
For recipients enrolled in major program BB, submit inpatient facility claims with admission dates:
Follow MHCP billing requirements for inpatient billing and not the requirements of the health plan. For example, if the hospitalization includes acute care and Medicare distinct rehabilitation admission, submit separate claims to MHCP, because separate NPIs and payments apply.
DHS contracts with county and private hospitals throughout Minnesota and South Dakota to provide extended inpatient hospital psychiatric treatment for MA fee-for-service eligible adults. The recipients are court committed or voluntarily admitted in lieu of commitment and are most often hospitalized on an acute psychiatric unit before admission to the contracted services. Payment is made at a negotiated rate per day.
Before billing for these services, refer to the following:
Refer to the Definitions section of Hospital Services home page.
Minnesota Statutes 144.50 (Hospitals, Licenses; Definitions), subd.1 (Inpatient hospital services)
Minnesota Statutes 245.4862 (Mental health urgent care and psychiatric consultation)
Minnesota Statutes 256B.0625, subd. 3g (Evidence-based childbirth program)
Minnesota Statutes 256L.03, subd.3 (Inpatient hospital services)
Minnesota Statutes 256.9686 (Definitions)
Minnesota Rules 9500.1090 to 9500.1140 (Purpose and Scope)
Minnesota Rules 9505.0300 (Inpatient Hospital Services)
Minnesota Rules 9505.0501 to 9505.0540 (Scope)
42 CFR 440.10 (Inpatient hospital services, other than services in an institution for mental diseases)