Inpatient Hospital Care

Overview  
An inpatient hospital is defined as a facility, other than psychiatric, that primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by or under the supervision of physicians, to patients admitted for a variety of medical conditions. 

Original Medicare  
Original Medicare provides coverage for the following services furnished to an inpatient of a participating hospital or of a participating critical access hospital, or in the case of emergency services or services in foreign hospitals, to an inpatient of a qualified hospital:  

1. Bed and board 
2. Nursing services and other related services  
3. Use of hospital or critical access hospital facilities  
4. Medical social services  
5. Drugs, biological, supplies, appliances and equipment  
6. Certain other diagnostic or therapeutic services  
7. Medical or surgical services provided by certain interns or residents-in-training  
8. Transportation services, including transport by ambulance  

Inpatient stays are defined by a benefit period of consecutive days during which medical benefits for covered services, with a certain specified maximum limitations, are available to the beneficiary. Under Original Medicare Part A, 60 full days of hospitalization plus 30 coinsurance days represent the maximum benefit period. The period is renewed when the beneficiary has not been in a hospital or skilled nursing facility for 60 days.  

BCBSNE Medicare Advantage Enhanced Benefit  
Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage Plans are Medicare Advantage Plans that provide at least the same level of benefit coverage as Original Medicare (Part A and Part B) and may provide enhanced benefits beyond the scope of Original Medicare within a single health care plan. This flexibility allows BBCBSNE to offer enriched plans by using Original Medicare as the base program and adding desired benefit options.  

Coverage for unlimited inpatient hospital care days is provided to members under BCBSNE Medicare Advantage. The member’s cost-sharing and coverage conditions are determined by BCBSNE. 

Please refer to the BCBSNE Medicare Advantage Explanation of Coverage (EOC) for the specific cost share amount associated with the enhanced benefit. 

Conditions for Payment  
The table below specifies payment conditions for unlimited inpatient hospital coverage.

Reimbursement 
BCBSNE Medicare Advantage plans’ maximum payment amount for inpatient hospital care is consistent with Original Medicare. Reimbursement is made through a prospective payment system in which Medicare payment is made based on a predetermined, fixed amount. This represents payment in full and providers are not allowed to balance bill the member for the difference between the allowed amount and the charge.

Member Cost-sharing  

• BCBSNE Medicare Advantage providers should collect the applicable cost-sharing from the member at the time of the service when possible. Cost-sharing refers to a flat-dollar copayment, a percentage coinsurance or a deductible. Providers can only collect the appropriate BCBSNE Medicare Advantage cost-sharing amount from the member.  
• If the member elects to receive a non-covered service, he or she is responsible for the entire charge associated with that service. 
• Providers may not have members sign an ABN to accept financial responsibility for noncovered items or services. 
• If there is any question about whether an item or service is covered, seek a coverage determination from Blue Cross before providing the item or service to the member. If a provider provides a noncovered item/service to a member without first obtaining a coverage determination, the member must be held harmless for all charges except for any applicable cost-share. 

To verify benefits and cost share, providers may call 888-505-2022. 

Billing Instructions for Providers  

1. Bill services on the CMS 1500 (02/12) or UB-04 claim form. 
2. Use the BCBSNE Medicare Advantage unique billing requirements.  
3. Report CPT/HCPCS codes and diagnosis codes to the highest level of specificity.  
4. Include your National Provider Identifier number on all claims.  
5. Send your claims to your local BCBS plan. 

Revision History:  
Policy Number: NEHMO 1005  
Policy Created: 09/21/2016  
Policy Revised: 01/20/2020  
Policy Effective: 01/01/2017