LE003 Adapting Internal Policies and Practices

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Brooklyn Presbyterian Hospital Acute Inpatient Hospital Admissions Payment Policy

Please Note: The policy described below is hypothetical. Purpose of the Billing Process The purpose of the hospital billing process is to obtain reimbursement for services and items rendered by the hospital. Reimbursement is received from patients, insurance carriers, and government programs. The hospital billing process begins when a patient arrives at the hospital for diagnosis and treatment of an injury, illness, disease, or condition. The patient’s demographic and insurance information is obtained and registered in the hospital’s information system. Physician’s orders or a requisition outlines the patient care services required. Patient care services and items provided during the patient’s stay are recorded on the patient’s account. Charges are posted to the patient’s account by various departments. When the patient leaves the hospital, all information and charges are prepared for billing.

Definition An acute inpatient hospital is a facility licensed as a hospital by the State Department of Public Health. This type of facility makes diagnosis and treatment available and offers provider services 24 hours a day but does not include any facility licensed as a chronic disease and rehabilitation hospital; any hospital licensed primarily to provide mental health services; or any unit of a facility licensed as a nursing facility, chronic disease unit, or rehabilitation unit.

An inpatient admission is a member’s admission to a hospital for the purpose of receiving inpatient services.

Authorization Requirements The rate of payment is determined by the effective date of a member’s inpatient admission and applies for the length of the admission (i.e., any rate change under the contract during the member’s stay will not apply). We require notification for emergency inpatient admissions.

We require prior authorization 5 business days prior to an elective admission.

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We require notification through an emergency services provider for all behavioral health inpatient admissions.

Billing and Reimbursement Providers must file a claim for hospital inpatient services through an 837i HIPAA-compliant file or on a 1234A form, using industry standard revenue codes.

An inpatient reimbursement rate is the rate in effect on the date a member begins an inpatient admission. The inpatient reimbursement rate includes all services a member receives during an inpatient admission, as applicable (see our Hospital Hierarchy Payment Policy). We will only reimburse for the portion of a patient's stay during which they were enrolled as a Health Plan—Network Health member.

Hospital Newborn Services We reimburse for inpatient services for well newborns. With prior authorization, we reimburse for inpatient services for boarder babies and newborns admitted to a neonatal intensive-care unit (see our Hospital Newborn Services Payment Policy).

Provider Preventable Conditions and Serious Reportable Events We do not reimburse for provider preventable conditions or serious reportable events (see our Provider Preventable Conditions and Serious Reportable Events Payment Policy).

Adapted from: Tufts Health Public Plans. (2015). Acute inpatient hospital admissions payment policy. Retrieved from https://network- health.org/Providers/Policies-and-Manuals/Payment-Policies/Acute-Inpatient-Hospital-Admissions-Payment-Policy.aspx