Inpatient Services

Introduction

Inpatient hospital services are those services and items normally furnished by a hospital for the care and treatment of patients. Such items and services must be provided under the direction of a physician in a state licensed institution maintained primarily for the treatment and care of patients with disorders other than mental disease.

Reimbursement Guidelines

Inpatient hospitals are reimbursed using All Patient Refined - Diagnosis Related Groupings (APR-DRG).

Providers must submit their room and board charges to EOHHS for the following fiscal year by the 15th of the month prior to the beginning of their fiscal year to ensure proper reimbursement for that fiscal year. The hospital should submit room and board charges on the schedule which follows in this section to ensure proper reimbursement. If a recipient’s hospital stay spans fiscal years and there is a change in the room and board rate, two separate claims must be submitted. One claim is for the dates of service up to and including the last day of one fiscal year, and the second claim begins with the first day of the new fiscal year.

The following procedures would be followed when billing for the hospital stays involving two fiscal year reimbursement rates:

The type of bill for the first bill would be 112 or 122 indicating an interim bill. The patient status would be 30 indicating still a patient. Only the room and board codes for dates of service prior to October 1st would be indicated on this bill. The from and to dates on the bill would be from admission to September 30th. For the second bill, the bill type (114 or 124) would indicate a final bill. This claim would include all ancillary charges for all dates of service as well as the room and board charges from October 1st until discharge. The patient discharge status would be other than 30 depending upon the type of discharge. The from date of service would be October 1st to discharge date. 

Co-Payment

There is no co-payment required from a recipient for an inpatient hospital stay.

Other Institutions

EOHHS will only reimburse the admitting facility for services provided to an eligible recipient during their entire length of stay. If a recipient is sent to another facility for services not available at the admitting facility, those charges must be billed on the admitting facility’s bill to EOHHS. If the second facility submits a bill to EOHHS, it will be denied. 

Covered Services

Refer to the listing of revenue codes in the appropriate Appendix.

All medically necessary services are covered for Medicaid eligible recipients, including:

Bed and board in semi-private accommodations;

nursing services (other than the services of a private duty nurse or attendant) and related services that are ordinarily furnished by the hospital for the care and treatment of inpatients, such as;

•  the use of hospital facilities
• medical social services
• drugs and biologicals for use in the hospital
• supplies, appliances and equipment for use in the hospital
• other diagnostic or therapeutic items or services not specifically listed but which are ordinarily furnished to inpatients

This is not an all-inclusive list.  

24 Hours Minimum Inpatient Stay

Hospital inpatient stays must be at least 24 hours. Recipients whose stay is less than 24 hours must be billed as outpatients.

Day of Admission

The day of admission is a covered day under Medicaid.

Limitations/ Special Requirements

Psychiatric Services

Payment is made to inpatient psychiatric hospitals only for those recipients under age 21 (up to age 22 if the individual is receiving such services immediately before reaching age 21) or age 65 and over. Psychiatric hospitals are reimbursed at a ratio of cost to charge (RCC) percentage.  

Prior Authorization

All inpatient admission for Medicaid recipients who are not covered by a RIte Care Managed Care Plan, or any other type of private or commercial medical insurance plan, must be reviewed by EOHHS contracted reviewer IPRO. This review is performed in order to ensure the appropriate treatment setting for the Program recipient.

Approval by IPRO is not an assurance of reimbursement.  Payment will only be made on behalf of patients whose eligibility under the Medicaid Program is verified through Provider Healthcare Portal or Customer Service Help Desk at 401-784-8100 for instate and long distance calls, or at 1-800-964-6211 for instate toll calls.  Any approval by IPRO relates only to the medical necessity of the hospitalization.

Pre-Admission Review

Pre-Admission Review is required for all inpatient hospital admissions. This includes both elective and non-elective admissions.

The purpose of Pre-Admission Review is to determine the medical necessity of admission of recipients to acute inpatient hospitals. Once admission is deemed medically necessary, this review will focus on determining the medical indications for hospitalization; the number of pre-operative days for which the recipient should be admitted to an acute inpatient hospital; and the total number of days appropriate for the recipient to remain in the acute inpatient hospital. The case manager will in all cases be either a registered nurse, or a physician registered or licensed to practice medicine in the State of Rhode Island who is eligible to sit for (Board Eligible) or has passed (Board Certified) his or her National Board Examination in the specialty in which he or she practices.

The health care provider is responsible for notifying the contractor by 4:30 p.m. of the second business day following the non-elective admission of a recipient to an acute inpatient hospital. The health care provider is responsible for notifying the contractor prior to a recipient’s elective admission. The health care provider may notify the contractor of an admission or pending admission by any of the following methods: telephone, facsimile, or electronic mail. A registered nurse, a board eligible or board certified physician will be appointed case manager for a particular admission and will assist with pre-admission review during normal business hours.

The case manager will speak with the admitting physician or the admitting physician’s designee regarding the recipient’s condition, the recommendation of such admitting physician or the admitting physician’s designee concerning the admission, the proposed method of treatment for such recipient and the date at which it is anticipated that the recipient will be discharged from the hospital.

Upon completion of the interview with the admitting physician or the admitting physician’s designee, the case manager will either approve the admission of the recipient to the health care facility for a specified number of days, reject the admission of the recipient to the health care facility, or suggest a modification to the proposed treatment or hospitalization.  

If the admission of the recipient is rejected, such decision shall be promptly reviewed by a board eligible or board certified physician for final determination. All adverse final determinations may be appealed by either the recipient or the health care facility in accordance with the appeals procedure described below.  

If the case manager does not approve the hospitalization and treatment recommended by the admitting physician or the admitting physician’s designee, the recipient admitting physician and acute inpatient hospital must be notified immediately. The contractor will then offer an expedited hearing on the same day as the adverse final determination. The expedited hearing will be a peer-to-peer discussion between the admitting physician or the admitting physician’s designee and the board eligible or board certified physician assigned by the contractor to review the case.

Length of Stay (LOS) Extension Review

The health care provider is responsible for notifying the Extension Review contractor when a recipient requires a LOS extension. The request must be made prior to the expiration of the initial LOS assignment.

The purpose of LOS Extension Review is to determine the medical necessity for the LOS extension. Requests for LOS extension will be reviewed closely to ensure appropriateness. The LOS extension review will focus on determining the medical indications for the extension; the number of days appropriate for the recipient to remain in the acute inpatient hospital. The case manager will be a registered nurse, or a physician registered or licensed to practice medicine in the State of Rhode Island who is eligible to sit for (Board Eligible) or has passed (Board Certified) his or her National Board Examination in the specialty in which he or she practices.

The PRO case manager must be contacted by the admitting physician or their designee prior to the expiration of the current LOS assignment before additional days can be certified. The minimum information to be communicated to the Contractor would include the number of additional days requested and the medical necessity for the extension.  

Upon completion of the interview with the admitting physician or the admitting physician’s designee, the case manager will either approve the LOS extension request for a specified number of days, reject the LOS request, or suggest a modification to the proposed LOS extension.

If the LOS extension of the recipient is rejected, such decision shall be promptly reviewed by a board eligible or board certified physician for final determination. All adverse final determinations may be appealed by either the admitting physician or the health care facility in accordance with the appeals procedure described below.  

If the case manager does not approve the LOS extension requested by the admitting physician or the admitting physician’s designee, the admitting physician and the acute inpatient hospital must be notified immediately. The contractor will then offer an expedited hearing on the same day as the adverse final determination. The expedited hearing will be a peer-to-peer discussion between the admitting physician or the admitting physician’s designee and the board eligible or board certified physician assigned by the contractor to review the case.  

Concurrent Reviews

Mental Health Services

Concurrent reviews are performed for all individuals who have been admitted to an acute care facility for the treatment of mental illness or substance abuse. Special attention will be given to concurrent review for cases in which the contractor or EOHHS has become aware that there may be no readily apparent medical necessity for hospitalization or a recipient has been admitted to a hospital as an inpatient for more than thirty (30) days.

Medical/Surgical Services

Concurrent reviews may be performed for individuals who have been admitted to a health care facility for receipt of medical and/or surgical services. Special attention will be given to concurrent review for cases in which the contractor or EOHHS has become aware that there may be no readily apparent medical necessity for hospitalization or a recipient has been admitted to a hospital as an inpatient for more than thirty (30) days.

Concurrent review for these cases will involve intensive scrutiny of the medical treatment plan in order to ensure appropriateness of plan and setting. The case manager will make such determinations based on interviews with the treating physician or other health care provider, as well as interviews with the recipient. Concurrent review will be conducted on-site or by telephone for in-state facilities and by telephone for out-of-state facilities.

A determination that the treatment being provided to the recipient is not medically necessary and/or an inpatient setting is no longer appropriate will result in a recommendation by the contractor that EOHHS no longer pay for such treatment for the recipient. The contractor will then evaluate the most appropriate setting for the recipient’s post-acute care. All adverse determinations must be reviewed by a board eligible or board certified physician, other than the case manager, prior to being made final. All final adverse determinations may be appealed by either the recipient or the health care facility in accordance with the appeals procedures below.

If the case manager does not approve the hospitalization and treatment recommended by the treating physician or the treating physician’s designee, the treating physician and the acute inpatient hospital must be notified immediately. The contractor will then offer an expedited hearing on the same day as the adverse final determination. The expedited hearing will be a peer-to-peer discussion between the treating physician or the treating physician’s designee and the board eligible or board certified physician assigned by the contractor to review the case.

Rehabilitation Review

An inpatient rehabilitation facility must notify the contractor of any impending admission. The proposed admission will be treated as a new admission separate from the acute inpatient hospital stay, even if rehabilitation activities are to be rendered in the same facility. Rehab admissions are subject to concurrent review. A facility may notify the contractor by telephone, fax or e-mail.

The purpose of Rehabilitation Review is to ensure that the recipient’s needs for rehabilitative services are recognized at the appropriate time. Rehabilitation review seeks to ensure treatment is performed in the most cost-effective setting and is administered by qualified professionals. It is anticipated that this type of service will result in a more independent level of functionality for the patient. The case manager will in all cases be either a registered nurse, or a physician registered or licensed to practice medicine in the State of Rhode Island who is eligible to sit for (Board Eligible) or has passed (Board Certified) his or her National Board Examination in the specialty in which he or she practices.

The case manager who shall be a registered nurse will pre-authorize inpatient admissions when rehabilitation services are medically necessary. Pre-authorization will determine the optimum setting for the patient, i.e., rehabilitation facility, skilled nursing facility, outpatient hospital services, or a home care program. Pre-authorization will be conducted using established rehabilitation admission criteria and intake procedure screens.

Determination of admission requests may be communicated to the facility via telephone, e-mail, or U.S. mail. The case manager will either approve the admission for the recipient to the facility; or if the case manager is unable to approve the admission, the case will be referred to a physiatrist for final determination.

If the case manager does not approve the admission, the admitting physician and facility must be notified immediately. If the contractor receives a telephonic request for further review, it must then provide an expedited appeal. A board eligible or board certified physician of like specialty, not involved in the original denial, will perform the review. A recommendation for non-certification will be made to the Division of Medical Services of EOHHS along with the medical rationale.

Upon receiving pre-authorization, recipients receiving rehabilitative services will be subject to concurrent review. Concurrent review will be performed to evaluate whether the recipient’s length of stay is appropriate and to ensure timely discharge. The case manager will make such determinations based on an on-site or telephone interview with the treating physician, or other health care provider, as well as interviews with the recipient when appropriate.

If the case manager determines the recipient’s stay in the facility is no longer appropriate, the recipient, admitting physician and facility must be notified immediately. If the contractor receives a telephone request for further review, it must then provide an expedited appeal. A board eligible or board certified physician of like specialty not involved in the original denial, will perform the review. A recommendation for non-certification will be made to the Division of Medical Services of EOHHS along with the medical rationale.

Retrospective Review

The contractor will perform retrospective reviews on the following types of cases: those randomly selected; cases in which the treating physician or acute inpatient hospital disagreed with the length of stay authorized by the contractor; those cases for whom Medicaid eligibility was determined during or after discharge and those cases receiving a technical denial due to timely notification. The purpose of retrospective review is to determine whether services rendered to the recipient were medically necessary.

Subsequent to the discharge of a recipient from the hospital the contractor will select cases for retrospective review.

A case manager, who shall be a registered nurse, will be assigned to audit a recipient’s medical record with attention to health care services received an medical outcome. The case manager will then issue a preliminary determination for each review.

Results of the retrospective review will be utilized to assess refund requests for services that were determined to be inappropriate or not medically necessary. Results of retrospective review will also be utilized to evaluate the cost-effectiveness of care received.  

Claims Billing Guidelines

Newborn Claims

Claims for newborns must be submitted with an actual or temporary social security number (SSN) for the child.  All newborn claims submitted will suspend for Medicaid Identification (MID) number verification. The claim will deny if the child’s SSN is not on the MMIS. This can be verified using the Healthcare Portal. These claims must be billed with admit status of 04, indicating newborn.  

Interim Billing

Long term inpatient stays can be billed using bill type 112 and 113. Interim bills must be for 30 days or more.  Claims billed with bill types 112 or 113 for services of less than 30 days will be denied.  Upon discharge, providers must recoup the paid interim bills and submit for the complete stay.