April 28, 2023
Effective Aug. 1, 2023, we’re implementing a new Outpatient Services Prior to an Inpatient Admission Clinical Payment and Coding Policy (CPCP038), utilizing guidance from the Centers for Medicare & Medicaid Services, which applies a three-day rule for certain services provided to outpatients who are later admitted as inpatients.
Blue Cross and Blue Shield of Illinois will review claims that fall under the three-day payment window. The three-day payment policy states that outpatient diagnostic and non-diagnostic services performed up to three days prior to a related admission to a hospital are considered inpatient services and should be submitted as part of the claim for inpatient reimbursement.
Under this new BCBSIL policy:
- If an admitting hospital has rendered related diagnostic or related non-diagnostic services three days preceding and/or on the date of a member’s inpatient admission, the services may be considered inpatient services and included as part of the inpatient reimbursement; or
- If an admitting hospital renders unrelated diagnostic or unrelated non-diagnostic outpatient services three days preceding and/or on the date of a member’s inpatient admission, the hospital may be reimbursed separately for the unrelated outpatient services.
What should I expect?
If BCBSIL determines the claim is for related services occurring within the three-day time frame as outlined above, we may ask you to submit a corrected claim.
What do I need to do?
Refer to our Clinical Payment and Coding Policies page to review in detail the new policy – Outpatient Services Prior to an Inpatient Admission, CPCP038.