Hospital Services

Revised: May 23, 2019

Overview

Hospital services include inpatient and outpatient services provided in a facility certified to participate in Medicare. Hospital services must be medically necessary and provided by or under the supervision of a physician, dentist or other provider having medical staff privileges in the hospital.

Sections

Critical Access Hospital (CAH) Services
Inpatient Hospital Authorization
Inpatient Hospital Services
Hospital In-reach Service Coordination (IRSC)
Outpatient Hospital Services

Definitions

Minnesota Critical Access Hospital (CAH): A facility designated as a critical access hospital must meet criteria established in federal legislation as well as criteria required by the state. For critical access hospital criteria, review Minnesota Rural Hospital Flexibility Program and Critical Access Hospital Information on the Minnesota Department of Health (MDH) website.

Diagnostic Related Groups (DRGs): An inpatient classification system that provides a means of relating the type of patients a hospital treats to the costs incurred by the hospital to establish prospective payment rates.

Emergency Department (ED) Care: Emergency department care must:

· Be provided in a hospital with a designated emergency department

· Reflect direct patient care, including active patient assessment, monitoring and treatment by hospital medical personnel such as physicians, nurses or lab and x-ray technicians

Medical records must document the emergency diagnosis and the extent of direct patient care.

Emergency department care does not include unattended waiting time.

Emergency department care and services are covered for a medical condition that manifests with acute symptoms (including severe pain) that, without immediate medical attention, could seriously jeopardize the physical or mental health of the individual or, with a pregnant woman, the health of the woman or unborn child. Labor and delivery is a medical emergency if it meets this definition.

· The Minnesota Health Care Programs member must be seen by the medical professional on the same day that the member contacted the medical professional in order for the situation to be considered an emergency

· The situation is not considered an emergency if the member contacts the medical professional and is not given an appointment for the same day of the call

· Prescheduled services are not considered an emergency

· Services provided as follow-up to initial emergency care are not considered emergency services

Inpatient: A member who has been admitted to a medical institution as an inpatient, as recommended by a physician or dentist, and meets one of the following criteria:

· Receives room, board and professional services in the hospital for a 24-hour period or longer

· Is expected to receive room, board and professional services in the hospital for a 24-hour period or longer even though it later develops that the member dies, is discharged, or is transferred to another facility and does not actually stay in the institution for 24 hours

Institution for Mental Disease (IMD): A hospital, nursing facility or other institution with more than 16 beds that is primarily engaged in providing diagnosis, treatments or care of persons with mental diseases. This includes treatment for mental health and substance use disorders.

Local Trade Area Hospital: A local trade area hospital is a hospital that is located in a state other than Minnesota but is in a county that is contiguous to the Minnesota border.

Outpatient: A member of an organized medical facility, or distinct part of that facility, who is expected to receive and who does receive professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the member remains in the facility past midnight.

Outpatient Hospital Services: Preventive, diagnostic, therapeutic, rehabilitative or palliative services provided:

· To outpatients

· By or under the direction of a physician or dentist

· By an institution that is licensed or formally approved as a hospital by an officially designated authority for state standard-setting and meets the requirements for participation in Medicare as a hospital

Outpatient Observation Status: Observation status is a method of billing for care received in a hospital that is not dependent on location, medical department or whether a patient bed is assigned to the member.

Patient: An individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward the maintenance, improvement or protection of health, or lessening of illness, disability or pain.

Psychiatric Residential Treatment Facility (PRTF): A PRTF provides active treatment to children and youth under age 21 with complex mental health conditions. This is an inpatient level of care provided in a residential facility rather than a hospital. PRTFs deliver services under the direction of a physician, seven days per week, to residents and their families, which may include individual, family and group therapy. Children and youth under the age of 21 are eligible based on medical necessity. PRTFs are not subject to the IMD exclusion; they qualify as accredited, licensed inpatient psychiatric hospitals.