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Important inpatient billing guidelines
May 1, 2023

This article is for acute care hospitals caring for our members

As a reminder, our existing Inpatient Acute Medical Admission payment policy applies to contracted providers rendering covered, medically necessary inpatient care. 

You must follow the below important billing guidelines for outpatient and observation services preceding an inpatient admission, as currently outlined in our payment policy.

For hospitals that are

Follow these billing guidelines

Reimbursed under APR-DRG methodology

  • Bill all outpatient services provided three days prior to the admission (except observation) as part of the inpatient claim.
  • Bill all observation services provided 48 hours prior to the admission as part of the inpatient claim.

Not reimbursed under APR-DRG methodology

  • Submit all outpatient charges on a separate outpatient claim with occurrence code 40 to enter the date of the scheduled admission.

Blue Cross reserves the right to perform post-payment review when services are not billed in accordance with our payment policies.

Related payment policies

To view payment policies, log in and go to Office Resources>Policies and Guidelines>Payment Policies.

  • Ambulance Transportation
  • General Coding and Billing
  • Inpatient Acute Medical Admission
  • Newborn and Neonatal Intensive Care Services
  • Non-Reimbursable Services
  • Observation Services
  • Serious Reportable Events
  • Third Party Services

Questions?

If you have any questions, please call Network Management and Credentialing Services at 1-800-316-BLUE (2583). As always, thank you for the care you provide to our members.

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