Incarcerated Member’s Eligibility:
A person residing in a correctional facility in Minnesota is eligible only for inpatient hospital services under Medical Assistance (MA).

· If the incarcerated person does not have MA, work with the correctional facility to complete the Medical Assistance (MA) Payment for Inpatient Hospital Coverage for Incarcerated People (DHS-6696G) (PDF) application process after the member 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.

· If the incarcerated member’s living arrangement is other than 68 or 69, please contact the Minnesota Department of Corrections.

· If the member was enrolled in a managed care organization (MCO) plan, the MCO is not responsible for covered services when the member is incarcerated.

· The correctional facility must complete the Medical Assistance (MA) Payment for Inpatient Hospital Coverage for Incarcerated People (DHS-6696G) (PDF) to submit the claims to MA FFS.

· If the correctional facility does not complete the Medical Assistance (MA) Payment for Inpatient Hospital Coverage for Incarcerated People (DHS-6696G) (PDF) the correctional facility will be responsible for inpatient stay cost.

Review the Incarceration section for more information.

Eligible Providers

An eligible facility, licensed as and meeting the definition of 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. Refer to Hospital Services for hospital services definitions.

Additional Services

MHCP covers professional services (for example, anesthesiologist and physician) in addition to outpatient or inpatient hospital services. MHCP may also cover other outpatient hospital services, such as lab, radiology, supplies and injectable drugs. Refer to the specific service sections of this manual for coverage and billing policy.

Coverage Limitations

Services provided in an outpatient or inpatient hospital setting are subject to the same requirements that apply to services by other providers, including:

· Requests for authorization (refer to Authorization): Submit transplant prior authorization requests to the authorization medical Review Agent by the physician’s office rather than the transplant facility. The transplant facility can request verification of prior authorization before the surgery by contacting the physician or by calling the MHCP Provider Resource Center. This also applies to Emergency Medical Assistance (EMA) coverage of Kidney Transplant Services.

· Inpatient Hospital Authorization (IHA) for admissions to hospitals located outside the local trade area, Medicare designated rehabilitation units, long term acute care hospitals, members under 21 years old at the time of admission to an institution for mental disease, members admitted to extended inpatient psychiatric services under contract with the Behavioral Health Division and EMA coverage of Kidney Transplant Services.

· Consent forms or statements of acknowledgment for hysterectomies, voluntary sterilizations and therapeutic abortions (refer to Reproductive Health/OB-GYN).

Refer to Critical Access Hospital (CAH) Services for billing instructions for critical access hospitals.

Copay Billing Policies

Copays apply to some services provided to MA members. Copay guidelines are listed in the Billing the Member section under Copays and Family Deductible.

Covered Services

Inpatient hospital services are covered if determined medically necessary (refer to Inpatient Hospital Authorization). Bill inpatient services provided by the same hospital on two separate patient care units by two medical services as one continuous admission under MHCP. This includes members 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.

Detoxification

MHCP covers inpatient admission for detoxification when certain medical criteria are met. Refer to the Inpatient Hospitalization for Detoxification Guidelines. 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 members 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 substance use disorder services designated for admissions covered under the behavioral health fund (BHF).

Incarceration

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. Associated inpatient hospital stay of the professional claims should bill with place of services 21, 51 or 61.

When a hospital admits and discharges an incarcerated person for inpatient admission on the same date, MHCP will not cover room and board. For these stays, and all other outpatient stays, submit the charges incurred on the discharge day to the responsible city or county correctional authority following the responsible city or correctional facility’s billing policies and procedures. Continue to bill the correctional facility for all outpatient services.

Incarceration inpatient hospital services billing:

· Bill on 837I claim format

· Follow Inpatient Services billing procedure

If the incarcerated member has Medicare as the primary insurance and Medicare does not cover an inpatient hospital service:

· Submit the inpatient charges to MHCP as primary

· Bill on 837I claim format

· Follow Inpatient Services billing procedure

· Leave coordination of benefits (COB) blank

· Follow the electronic claim attachments instructions

· Attach the Medicare’s explanation of benefits (EOB) for date of services

Inpatient-Only Procedures

Medicare identifies procedures that must be performed in an inpatient setting. MHCP follows Medicare guidelines for payment for inpatient-only procedures; MHCP will pay for these procedures only on inpatient claims.

MHCP Members with Third Party Liability
Follow the Medicare and Other Insurance policy and procedures.

Noncovered Services

The following inpatient hospital services are not covered:

· Leave days, leaves of absence and reserve beds

· Inpatient substance use disorder treatment (covered under the BHF and administered at the county or tribal level)

· Hospitalizations designated as noncovered services in statutes or rules

· Charges related to hospital care for investigative services, plastic or cosmetic surgery, which are not covered unless determined medically necessary through the medical review authorization process, and services designated as noncovered in statutes or rules. A physician may donate their services to perform a noncovered service, but MHCP does not cover facility fees, ancillary charges and other procedure or service charges related to performing the noncovered services

· Outpatient claims for a person incarcerated in a state or local correctional facility are the responsibility of the Minnesota Department of Corrections or other local corrections authority

Billing

Submit claims electronically using MN–ITS 837I Inpatient Services. Use the UB-04 Data Specifications Manual for reference.

MHCP Coverage Ended During Inpatient Stay

MHCP generally approves MHCP member eligibility on a monthly basis. If a member’s MHCP coverage ends during their inpatient stay, bill:

· Type of Bill 111

· Dates member is eligible for coverage only

· Occurrence code 25 and date coverage is no longer available

· Occurrence code 42 and date of discharge

· Patient status 30

If the member later becomes retroactively eligible for the entire inpatient stay, replace the claim, entering the statement covers period dates as the entire inpatient stay.

MHCP Eligibility Begins After the Date of Inpatient Admission

If a member’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:

· Admission Date: enter the actual date of hospital admission

· Statement Date (From) and Statement Date (To): enter the date eligibility began through the discharge date or final billing date

· Remove all procedure codes that occurred before eligibility began

· Remove all revenue codes and charges that were incurred before the eligibility date

Inpatient Hospital Services when First Date of Eligibility is the Discharge Date

When a hospital admits a member as an inpatient and the first day of eligibility is the discharge date, MHCP will not cover room and board. 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:

· From–To Date: enter the date eligibility began which is also the discharge date and final billing date

· Remove all procedure codes that occurred before eligibility began

· Remove all revenue codes and charges that were incurred before the eligibility date

Inpatient Admission Following Outpatient Services for Discharge Date

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 Oct. 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 are included on the inpatient claim when outpatient services occur prior to admission.

Use the following information to report an inpatient admission that follows the outpatient services date for discharge date on or after October 1, 2015:

· Outpatient days are no longer included in the covered days when the admitting hospital delivers outpatient services immediately prior to the inpatient admission

· Covered days and noncovered days:

· Include outpatient services on the inpatient claim when outpatient services occur prior to admission

· Do not count the day of discharge

· Do not include the outpatient days in the covered days count

· Covered days are equivalent to room and board days

· Admission date: Report the actual admission date

· Procedure codes: Use ICD10-CM procedure codes for the date service was rendered

Inpatient Hospital Services when Inpatient Authorization is Denied

When a member is admitted to a hospital as an inpatient and Inpatient Hospital Authorization (IHA) is denied, or the member does not meet inpatient criteria, MHCP may cover services provided in the hospital when billed as outpatient hospital services if the following apply:

· The member was in the hospital for less than 48 hours (total), or up to 72 hours with documentation

· The stay was not billed as an inpatient stay

· The claim indicates admission hour and discharge hour (code 99, hour unknown) is not acceptable

Trauma Response Team Associated with Hospital Critical Care Services

If a trauma response team is activated, as described by the national uniform billing committee (NUBC) guidelines, and the hospital provides at least 30 minutes of critical care for which CPT code 99291 is reported, then:

· Bill using code G0390

· Only one unit per day is payable

· Trauma activation is a one-time occurrence

If the hospital provides less than 30 minutes of critical care, you cannot report health care common procedural coding system (HCPCS) G0390.

Interim Billing

Do not submit inpatient hospital billing until the hospital has discharged the member. 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 Payer Claim Control Number field on the Claim Information tab in MN–ITS Direct Data Entry or in the Loop: 2300, REF02 in MN–ITS Batch.

Deliveries and Births

Submit separate claims for a mother and their newborn. A newborn whose mother is enrolled in a managed care organization (MCO) at the time of birth will be retroactively enrolled in the same MCO for the birth month, unless the newborn meets an exclusion. Refer to Excluded Members section. Use admission Type ‘4’ only for the baby and only for the admission when the birth occurred. Refer to Laboratory and Pathology Services for Minnesota Department of Health (MDH) Newborn Metabolic Disorder Screening.

Long-acting reversible contraceptives (LARC), given during an admission for labor and delivery, can be billed outside of the inpatient DRG payment. Refer to Billing in the Family Planning section for how to bill.

Birth Weight Requirement

With the implementation of the APR-DRG grouper, 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 birth weight 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.

Physical Rehabilitation

Submit separate claims for members with admissions to a Medicare-designated rehabilitation unit using the rehabilitation unit’s national provider identifier (NPI). The hospital must seek an IHA for rehabilitation admissions. If a hospital transfers a member between acute inpatient care and inpatient rehabilitation, each rehabilitation admission requires a different IHA number, unless the hospital combines the admissions.

If the admissions to a Medicare-designated rehabilitation unit are not issued a separate IHA number by the medical review agent, label the days in the acute inpatient setting as leave of absence days. Similarly, if admission to an acute inpatient setting does not meet criteria for separate payment (refer to Inpatient Hospital Authorization), identify the days in the rehabilitation setting as leave of absence days.

For example, a member 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.

Medicare Exhausted Benefits for Members with Dual Eligibility

If an MA member 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:

· Submit the inpatient charges to MHCP as primary

· Follow the electronic claim attachments instructions

· Attach the Medicare (Part A and Part B) Explanation of Benefits (EOB) for all dates of service

· Write “Medicare Part A Benefits Exhausted” on top of the Medicare EOB

Medicare Part B Coverage Only for Members with Dual Eligibility

If an MA member has dual eligibility with Medicare, but has only Part B coverage (no Part A coverage-not a benefits exhausted situation), submit the claim as follows:

· Submit the Medicare Part B coverage services to Medicare

· Submit the inpatient charges to MHCP as primary once Medicare has processed the Part B services

· Follow the electronic claim attachments instructions

· Attach the Medicare Part B EOB for all dates of service

· Write “No Part A Coverage, only Part B Coverage” on top of the Medicare EOB

Spenddown

When members 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 Loop 2300, DTP03 in MN–ITS Batch. The date of admission must contain the date of the member’s admission to the inpatient hospital.

Inpatient Certified Registered Nurse Anesthetist (CRNA)

Hospitals must exclude 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:

· A CRNA independent or employed by a physician

· A CRNA employed by a hospital

· An entity or group not enrolled as a hospital that is billing CRNA services

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.

MinnesotaCare

Bill inpatient hospital services provided to a MinnesotaCare member to the member’s MCO.

For members enrolled in Managed Care Organizations (MCO), submit inpatient facility claims with admission dates to the member’s MCO.

Follow MHCP billing requirements for inpatient billing and not the requirements of the MCO. For example, if the hospitalization includes acute care and Medicare distinct rehabilitation admission, submit separate claims to MHCP, because separate NPIs and payments apply.

Services with Gender or Procedure Code Conflict

Report condition code 45 (gender incongruence – characterized by a marked and persistent incongruence between an individual’s experienced gender and sex at birth) to identify claims for inpatient or outpatient services that can be subject to gender-specific editing. This condition code allows the gender-specific edit to be bypassed. Refer to Services with a Gender or Procedure Code Conflict under Physician and Professional Services in the MHCP Provider Manual for how to bill on a professional claim.

Extended Inpatient Psychiatric Services under Contract with Minnesota Department of Human Services (DHS)

DHS contracts with county and private hospitals throughout Minnesota to provide extended inpatient hospital psychiatric treatment for MA fee-for-service eligible adults and children. The members 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. MHCP pays at a negotiated rate per day.

Before billing for these services, refer to the following:

· For members admitted to an extended inpatient psychiatric program under contract with DHS directly from an acute care hospital, code the acute care hospital stay using patient discharge code 02 or 65. Contracting hospitals should refer to the Extended Inpatient Psychiatric Services contract for limited medical services that MHCP considers outside the contract per diem rate and hospitals can submit separately for outpatient payment.

· MA members admitted to an Extended Inpatient Psychiatric Services requires an Inpatient Hospital Authorization (IHA).

· Bill extended inpatient psychiatric stays separately from acute care hospital stays

Forms and Resources

· Extended Psychiatric Inpatient Treatment Medical Assistance (MA) Review Procedures (DHS-4905A) (PDF)

· Weekly Review Guidelines Continued Stay in Psychiatric Inpatient Bed (DHS-4905B) (PDF)

· Extended Psychiatric Inpatient Initial Review (DHS-4905C) (PDF)

· Extended Psychiatric Inpatient Weekly Bed Review (DHS-4905D) (PDF)

· Extended Psychiatric Inpatient Discharge Summary Review (DHS-4905F) (PDF)

· Payment methodology for inpatient hospitals

Definitions

Refer to the Definitions section under Hospital Services in the MHCP Provider Manual.

Legal References

Minnesota Statutes, 144.50, subdivision 1 (Hospitals, Licenses; Definitions; License required)
Minnesota Statutes, 245.4862 (Mental Health Urgent Care and Psychiatric Consultation)
Minnesota Statutes, 256B.055, subdivision 14 (Persons detained by law)
Minnesota Statutes, 256B.0625, subdivision 3g (Evidence-based childbirth program)
Minnesota Statutes, 256L.03, subdivision 3 (Inpatient hospital services)
Minnesota Statutes, 256.9686 (Definitions)
Minnesota Rules, 9500.1090 to 9500.1140 (Hospital Medical Assistance Reimbursement)
Minnesota Rules, 9505.0300 (Inpatient Hospital Services)
Minnesota Rules, 9505.0501 to 9505.0540 (Hospital Admissions Certification)
Minnesota Rules, 9505.0270 (Dental Services)
Code of Federal Regulations, title 42, section 440.10 (Inpatient hospital services, other than services in an institution for mental diseases)

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