Outpatient Services Prior to Admission

Effective Date: November 22, 2020

Purpose:
To provide reimbursement guidelines for outpatient services rendered prior to an inpatient admission.

Scope:
Products included:

  • NJ FamilyCare/Medicaid
  • Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Definitions:

  • Pre-Admission Testing: Includes any service related to a patient’s planned inpatient admission or same day surgery that is performed on the day of, or within the 72-hour period prior to the day of, a patient’s planned inpatient admission or same day surgery service.
  • Three Day Payment Window: The three (3) days prior to and including the date the member is admitted as an inpatient.

Policy:
Outpatient preadmission services, including pre-admission testing, related to the member’s stay are included in the facilities inpatient reimbursement for the (3) three days prior to and including the day of the member’s admission. For example, if a member is admitted as an inpatient on Wednesday, then Sunday, Monday, Tuesday, or Wednesday are all part of the three (3) day window. Preadmission services consist of all related diagnostic outpatient services, pre-admission testing and admission-related outpatient non-diagnostic services.

Outpatient preadmission services that are not related to a member’s admission performed on the day of or in the three (3) days prior to and the day of a patient’s inpatient admission may be considered for separate reimbursement.

Procedure:
Horizon NJ Health shall deny preadmission testing and preadmission services when billed within three (3) days prior to a related inpatient admission at the same facility.

Horizon NJ Health shall consider for reimbursement preadmission services not related to the inpatient stay when billed within three (3) days prior to an inpatient admission when submitted by the same facility.

References:
Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf

Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, 90.7

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Benefit Limitations
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.