Humana‘s policy follows The Centers for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual Pub. 100-04, Transmittal 299, which states:
In cases when a hospital utilization review committee determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the patient’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 patient, 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 individual is still a patient of the hospital;
- The hospital has not submitted a claim to Medicare or Humana 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 13x or 85x bills for services furnished to a patient whose status was changed from inpatient to outpatient, the hospital is required to report Condition Code 44 in one of the 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, a hospital may bill the Humana Medicare Advantage plan for services that would be Part B outpatient services as long as the following criteria are met:
- Service was provided to the beneficiary prior to the point of inpatient admission in the three-calendar-day (or one-calendar-day for a non-inpatient prospective payment system hospital) payment window prior to the admission. This includes services that require an outpatient status (see the "Medicare Claims Processing Manual" Chapter 4, Section 10.12, at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c02.pdf). These services should be billed on a 13x claim.
Services provided prior to the point of inpatient admission are outpatient services and may not be included on the 12x Part B inpatient claim; services provided after the point of admission are inpatient services and may not be included on the 13x Part B outpatient claim. Two complementary claims are therefore necessary if some services are provided before admission and others are provided after admission. In placing services on the appropriate claim, hospitals should use the same billing and coding rules used for assigning dates of service to services that cross midnight, using the start of the service to determine correct claim placement, unless other specific instructions are provided, and ensuring that services are not double billed. If inpatient- only services, such as procedures on the inpatient-only list, were delivered prior to the point of admission, they cannot be paid because they were provided as outpatient services; they may not be reported on the 12x Part B inpatient claim because they were provided prior to the point of admission. If outpatient-only services, such as outpatient observation, were continued after the point of admission, the post-admission services cannot be paid because they were provided as inpatient services; the time may not be included on the 13x Part B outpatient claim because it was provided after the point of admission.
Claims for 12x and 13x rebilling must be submitted with Condition Code W2.
Reference: Medicare Claims Processing Manual, Chapter 4, Section 10.12 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c02.pdf)
Humana will follow all federal and state laws and regulations, Humana policies and procedures and any applicable contract language. When more than one state is impacted by a particular issue, to allow for consistency, Humana will follow the most stringent requirement(s). 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.