Here are the latest updates to our payment policies. You’ll need to log in to see the policy updates.
- New Policy - Inpatient Acute Transfers from DRG Hospitals (effective with dates of service 07/05/2018 and after)
We’ll adjust how we reimburse patient transfers from any acute care hospital to another acute care facility, effective for dates of service on and after July 5, 2018. These short hospital stays will be reimbursed a calculated per diem rather than paid a full DRG calculated rate for the short stay. This policy will only be applicable to acute care hospitals reimbursed by DRG.
When an inpatient is transferred to another acute care hospital for additional or continued care not available in the initial hospital, we’ll handle reimbursement in the following way:
If the transferring hospital is contractually reimbursed on a DRG payment methodology, we’ll reimburse the transferring facility a graduated per diem rate. This per diem rate will be based on the DRG case rate for the services rendered, and it won’t exceed the full DRG rate for the patient’s stay in the transferring hospital.
- Facility Fees: Clinic Services, Professional Fees, and Specialty Services-Treatment Room
Medicare Primary crossover claims will be exempt from this policy. (A Medicare Crossover Claim occurs when Premera is secondary coverage, not a supplemental policy.)
- Anesthesia Guidelines
Created new section Codes/Coding Guidelines and added full description of code(s) mentioned in Policy section
- Anesthesia Modifiers
Annual review; no changes to the policy
- Home Birth Kit Supplies
Added new section Codes/Coding Guidelines and added full description of code(s) mentioned in Policy section
- Blood Draw (Venipuncture)
Added new section Codes/Coding Guidelines and added full description of code(s) mentioned in the Policy section
- Modifier 79 – Unrelated Procedure/Service by Same Provider During Postoperative Period
Added the last paragraph to the Policy section to indicate that the three modifiers noted don’t bypass any multiple procedure reductions
- Modifier SL – State Supplied Vaccine
Added clarification in the last paragraph in the Policy section that all other submissions of the SL modifier by other providers than the Vaccine Association will be denied reimbursement
- New and Established Patient Guidelines
Annual Review; no changes to the policy
- Prolonged Services for Labor Management (Codes 99354, 99355, 99356, 99357)
Added new section Codes/Coding Guidelines and added full description of code(s) mentioned in the Policy section
- Hospital or Hospital System Readmissions
Additional revisions made to the bulleted items at the end of the Policy section