• Submit partial hospitalization services with the following revenue codes:
• 0912, 0913 or 0915
o If a separate contract for the hospital and psych DPU are in effect, submit partial hospitalization services and inpatient services on separate UB-04 claim forms.
• Florida Blue considers partial hospitalization to be an outpatient service.
• Partial hospitalization for psychiatric or substance abuse admissions is calculated as follows:
o Partial Days (including beginning and ending dates) x Per Diem.
DRGs are statistically meaningful medical groupings used for the purpose of categorization and reimbursement of hospital services.
• DRGs allow for more uniform billing based upon the member’s diagnosis and procedures, age, sex, and discharge status.
• Reimbursement for DRG cases is based on discharge date.
• Exception: A newly established participating provider, under a DRG contract, will have the first year of claims reimbursed based on the admission date of the inpatient claim.
• Deaths and transfers are reimbursed based on the assigned DRG and payment hierarchy logic. There are no special reimbursement arrangements applicable to deaths and transfers.
• A list of DRGs, along with length of stay trim points and relative weights, is contained in your hospital’s Agreement.
Outlier cases are exceptions to typical inpatient DRG cases. Refer to your Agreement for which outlier method applies.
There are three types of outlier cases but not limited to:
• Low length of stay outlier – Low Length is a case in which the member stays in the hospital fewer days than the low length of stay trim point.
• High length of stay outlier – High Length is a case in which the member stays in the hospital a greater number of days than the high length of stay trim point.
• High charge outlier- High charge is a case in which total covered charges exceed the high charge threshold.