The CMS Medicare Claims Processing Manual Pub. 100-04, Transmittal 299, states:
In cases where a hospital utilization review committee determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the beneficiary’s status from inpatient to outpatient and submit an outpatient claim (TOBs 13x, 85x) for medically necessary Medicare Part B services that were furnished to the beneficiary, provided all of the following conditions are met:
- The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
- The hospital has not submitted a claim to Medicare for the inpatient admission;
- A physician concurs with the utilization review committee’s decision; and
- The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.
When the hospital submits a 13x or 85x bill for services furnished to a beneficiary whose status was changed from inpatient to outpatient, the hospital is required to report Condition Code 44 in one of Form Locators 24-30, or in the ANSI X12N 837 I in Loop 2300, HI segment, with qualifier BG, on the outpatient claim.
When an inpatient admission is determined not to be medically necessary for inpatient after a patient was discharged, the hospital may submit ancillary charges on the 12X bill type after the original paid amount is recovered. These services are listed in the CMS Benefit Policy Manual, Ch. 6, Section 10
There should be no member responsibility for these instances.
Humana will follow all federal and state laws and regulations. When more than one state is impacted by a particular issue, to allow for consistency, Humana will follow the most stringent requirement.
This standard is subject to change or termination by Humana at any time. Humana has full and final discretionary authority for its interpretation and application. This standard supersedes all other Humana policies, standards or information conflicting with it.