Newborn Payment Policy

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Newborn Payment Policy

The following payment policy applies to Tufts Health Plan contracted inpatient facilities and professional providers who render newborn services in an inpatient setting. This policy applies to Commercial1_{and Tufts Health Freedom Plan products.}

Note: Audit and disclaimer information is located at the end of this document.

POLICY

Tufts Health Plan covers well and sick newborn services. All incurred inpatient well newborn services are included in the payment for the mother’s obstetrical stay provided that the mother is a Tufts Health Plan member. If the newborn is not being added as a dependent to either the mother or father’s plan, coverage for well newborn care will cease upon the earlier of: the mother’s discharge; or 48 hours for a vaginal delivery; or 96 hours for a caesarian delivery. Additional payment for newborns requiring sick newborn care is contingent upon the newborn being enrolled for family coverage.

Tufts Health Plan covers newborn services in accordance with federal and applicable state mandate coverage including, but not limited to the provisions of, Chapter 175 Section 47C, Chapter 175 Section 47F and Chapter 176G Section 4.

Tufts Health Freedom Plan Products Only:

Newborns i.e., child of a dependent child/grandchild may be eligible for coverage from birth to 31 days under the grandparent2_.

GENERAL BENEFIT INFORMATION3

Services and subsequent payment are based on the member's benefit plan document. Providers and their office staff should use self-service channels to verify effective dates and copayments for members prior to initiating services.

Refer to the Electronic Services section of our website for our self-service channel options. Benefit specifics should be verified prior to initiating services by logging on to our website or by contacting Provider Services.

PREVENTIVE SERVICES

Due to the Patient Protection and Affordable Care Act (commonly referred to as federal health care reform), with the exception of groups maintaining "grandfathered" status, all Tufts Health Plan plans are required to provide 100% coverage for preventive care services. Grandfathered groups are not subject to this requirement, but many of these groups have opted to cover preventive services with no cost sharing.

This means that most members will have no cost-sharing responsibility when preventive services are rendered by an in-network provider. Members may still be required to pay a copayment, deductible or coinsurance for preventive services received from out-of-network providers (PPO and POS plans), or for non-preventive services received in conjunction with a preventive services visit. Refer to the Preventive Services list for a complete list of services that have been deemed preventive in nature.

MEMBER RESPONSIBILITY

Copayments, deductible and/or coinsurance may apply pursuant to the member’s benefit plan document.

Tufts Health Plan recommends not billing the member for the deductible and/or coinsurance until the claim has processed so that the appropriate member responsibility can be determined. Both the provider’s Explanation of Payment (EOP) and the Electronic Remittance Advice (ERA) will reflect the member’s responsibility amount.

1_{Commercial products include HMO, POS, PPO & CareLink}SM_{when Tufts Health Plan is Primary Administrator.} 2_{Per N.H. RSA 415.22.}

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Note: Tufts Health Plan will not allow the use of a so-called "waiver" to circumvent or override the provider's obligations under the applicable participation agreement with regard to services covered under the member's plan. By way of illustration and not limitation, the waiver is of no validity when applied to missed filing deadlines, provider's authorization requirements and attempts to collect payments other than applicable copayments, coinsurance or deductibles.

INPATIENT ADMISSION REQUIREMENTS Definition

An inpatient notification, formerly known as preregistration, is notification to Tufts Health Plan via web, fax or telephone that a member is being admitted for inpatient care regardless of whether Tufts Health Plan is the primary or secondary insurer. Inpatient notification is completed by the facility where the member is scheduled to be admitted or may be completed by the specialist provider.

Inpatient Notification Event

Tufts Health Plan requires notification for any member who is being admitted for inpatient care regardless of whether Tufts Health Plan is the primary or secondary insurer.

Authorization for coverage of DRG inpatient services is determined using Tufts Health Plan Medical Necessity Guidelines and/or criteria published by Truven Health Analytics, InterQual® _{criteria and} nationally-recognized medical necessity criteria.

Providers can submit an inpatient notification event by:

 Logging in to the secure section of our website

 Faxing to the Precertification department at 617.972.9590 or 800.843.3553

Providers can log on to the Tufts Health Plan secure website to view the notification event and status of the event in real-time, 24 hours a day, 7 days a week.

If a provider is not web-enabled or registered on the Tufts Health Plan secure website at the time of submission, he or she may request a faxed copy of their notification event.

An inpatient notification event submitted via fax is available for viewing on the provider website. If the provider completes the inpatient notification event via telephone, the inpatient admissions staff, within the Precertification department, will verbally communicate the inpatient notification number for approval for coverage. This information will also be viewable on the Tufts Health Plan provider website.

Note: An inpatient notification does not take the place of a referral or prior authorization requirements for a service.

Newborns requiring inpatient services, beyond the mother’s discharge date, require their own inpatient notification. However, notification is not a guarantee of payment.

The following information is required when notifying Tufts Health Plan regarding a member seeking inpatient care:

 Member's name

 Member's Tufts Health Plan identification (ID) number

 Hospital name

 Attending physician name

 Date of admission and/or service

 Primary, and any additional, diagnoses and procedure information

When the inpatient notification process is complete, the inpatient notification will be communicated. The notification number for coverage confirms inpatient level of care.

Discharge date and inpatient notification number are conditions of payment. The discharge date must be reported within one (1) business day of discharge.

For information on extended care, refer to the Skilled Nursing Facility Payment Policy.

Obstetrical Admissions

Obstetrical admissions that will result in the planned delivery of a newborn do not require inpatient notification.

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Obstetrical admissions that fall outside of the mandated 48 hours for a vaginal delivery or 96 hours for a caesarian delivery require inpatient notification. Obstetrical admissions that are not for a planned delivery are subject to Tufts Health Plan’s notification requirements.

Services Requiring Prior Authorization

While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you will need to make sure that prior authorization has been obtained.

Some procedures require prior authorization with the Tufts Health Plan Precertification Department. Refer to the Guidelines section of our website for additional information. Refer to the CareLink Prior Authorization List for a list of procedures, services and items requiring prior authorization for CareLink members.

For a complete description of Tufts Health Plan’s authorization and notification requirements, refer to the Authorization chapter within the Tufts Health Plan Commercial Provider Manual.

For authorization information and/or prior authorization requirements for members using the PHCS (also known as MultiPlan) network, contact American Health Holding.

BILLING INSTRUCTIONS

 Submit the most updated industry-standard codes.

 Submit birthweight in grams for each newborn claim submitted. Refer to Processing Information on pages 3 and 4 of this policy.

 Accurate and timely claims processing is contingent upon the newborn’s enrollment in the Plan.

 Submit claim(s) to the mother’s primary insurance carrier.4

 Submit a separate claim for each newborn if there are multiple births.

 Submit claim(s) under the mother’s ID # when the newborn has not been added to the Plan.

 Submit claim(s) under the newborn’s ID # when the newborn has been added to the Plan.5

 Submit the appropriate Revenue Codes when billing for facility charges.

 Submit standard CPT modifiers in accordance with the appropriate CPT procedure code(s).

 For more information regarding modifiers refer to the Modifier Payment Policy.

Circumcision

Circumcision for newborns is covered: under the mother’s inpatient notification, as a newborn charge and when performed in the hospital by a licensed physician.

 Tufts Health Plan will not cover any circumcision that is not performed by a licensed physician.

 Circumcisions performed in the home are not covered.

 Circumcisions performed in any setting other than a hospital, day surgery, or physician’s office will not be covered.

 If a newborn is circumcised after discharge from a hospital, a surgical day care copayment (SDC) may apply when performed in an outpatient setting. If performed in a doctor’s office or community health center, the member would be responsible for an office visit copay.

Note: Annually and quarterly, HIPAA medical code sets6_{undergo revision by CMS, AMA and CCI.} Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-CM diagnosis codes. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes.

EDI Claim Submitter Information

 Submit claims in appropriate HIPAA compliant format. Claims billed with non-standard codes will reject if billed electronically.

 Submit a corresponding CPT and/or HCPCS code for every Revenue Code submitted. Tufts Health Plan acknowledges that certain Revenue Codes may not have a corresponding CPT and/or HCPCS code; however, in all cases the provider is encouraged to find a procedure code for every Revenue Code.

4_{In accordance with coordination of benefits, if it is the intent to add the newborn to a plan other than the birth mother's, submit} claims in accordance with applicable instructions/rules of such other carrier.

5_{If a claim has been submitted under the mother’s ID #, a duplicate claim should not be submitted under the newborn’s ID #.}

Claims must be submitted in accordance with Tufts Health Plan’s Claims Submission Policy.

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Paper Claim Submitter Information

 Submit claims on an official claim form. Claims billed with non-standard codes will deny.

 All paper claims must be submitted on official, standard red claim forms. Black and white versions of these forms, including photocopied and faxed versions, will not be accepted and will be returned with a request to submit on the proper claim form.

 Submitted forms deemed incomplete will be rejected and returned to the submitter. The rejected claim and a letter stating the reason for rejection will be returned to the submitter, and a new claim with the required information must be resubmitted for processing.

Newborn Care Services CPT Procedure Codes

The following table lists CPT procedure codes used to report services to newborns birth to 28 days.

The absence or presence of a CPT procedure code is not an indication and/or guarantee of coverage and/or payment.

Procedure

Code Description

99460 Initial hospital or birthing center care, per day, for evaluation and management of _{normal newborn infant} 99461 Initial care, per day, for evaluation and management of normal newborn infant seen

in other than hospital or birthing center

99462 Subsequent hospital care, per day, for evaluation and management of normal _newborn 99463 Initial hospital or birthing center care, per day, for evaluation and management of _{normal newborn infant admitted and discharged on the same date} 99464 Attendance at delivery (when requested by the delivering physician) and initial

stabilization of newborn 99465

Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output

Criteria for Well and Sick Newborns

Compensation and authorization are dependent upon the status of the newborn, either defined as well or sick based on the criteria outlined below. ICD-CM diagnoses; and the Revenue Code(s) on the claim are used to determine the status of the newborn (well or sick).

Well Newborn Criteria

Compensation for services for newborns that are deemed well will be based on the following information:

 Newborn is without perinatal complications requiring medical or surgical intervention.

 Well diagnosis only.

 Industry-standard Revenue Codes for routine nursery for the entire length of stay (LOS).

Exhibit 1- Tufts Health Plan considers the following ICD-9 diagnoses Well: ICD-9 Diagnosis

765.29 37 or more completed weeks of gestation

766 Disorders relating to long gestation and high birthweight 766.0 Exceptionally large baby

766.1 Other "heavy-for-dates" infants 766.21 Post-term infant

766.22 Prolonged gestation of infant

767.11 Epicranial subaponeurotic hemorrhage 767.19 Other injuries to scalp

767.2 Fracture of clavicle

770.13 Aspiration of clear amniotic fluid without respiratory symptoms 770.15 Aspiration of blood without respiratory symptoms

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ICD-9 Diagnosis

770.17 Other fetal and newborn aspiration without respiratory symptoms 770.85 Aspiration of postnatal stomach contents without respiratory symptoms 771.6 Neonatal conjunctivitis and dacryocystitis

771.7 Neonatal Candida infection

772.6 Cutaneous hemorrhage

774.6 Unspecified fetal and neonatal jaundice

777.3 Hematemesis and melena due to swallowed maternal blood 777.4 Transitory ileus of newborn

778.1 Sclerema neonatorum

778.6 Congenital hydrocele

778.7 Breast engorgement in newborn 779.83 Delayed separation of umbilical cord

779.84 Meconium staining

Exhibit 2- Tufts Health Plan considers the following ICD-10 diagnoses Well. These codes are effective for date of service on or after October 1, 2015:

ICD-10 Diagnosis

P08.0 Exceptionally large newborn baby P08.1 Other heavy for gestational age newborn

P08.21 Post-term newborn

P08.22 Prolonged gestation of newborn P12.0 Cephalhematoma due to birth injury

P12.1 Chignon (from vacuum extraction) due to birth injury P12.2 Epicranial subaponeurotic hemorrhage due to birth injury P12.3 Bruising of scalp due to birth injury

P12.4 Injury of scalp of newborn due to monitoring equipment

P12.81 Caput succedaneum

P12.89 Other birth injuries to scalp P12.9 Birth injury to scalp, unspecified P13.4 Fracture of clavicle due to birth injury

P24.10 Neonatal aspiration of (clear) amniotic fluid and mucus without respiratory symptoms P24.20 Neonatal aspiration of blood without respiratory symptoms

P24.30 Neonatal aspiration of milk and regurgitated food without respiratory symptoms P24.80 Other neonatal aspiration without respiratory symptoms

P37.5 Neonatal candidiasis

P39.1 Neonatal conjunctivitis and dacryocystitis P54.5 Neonatal cutaneous hemorrhage

P59.9 Neonatal jaundice, unspecified P76.1 Transitory ileus of newborn

P78.2 Neonatal hematemesis and melena due to swallowed maternal blood

P83.0 Sclerema neonatorum

P83.4 Breast engorgement of newborn P83.5 Congenital hydrocele

P96.82 Delayed separation of umbilical cord

P96.83 Meconium staining

Sick Newborn Criteria

Coverage for sick newborns will be based on the following information:

 Sick diagnosis

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Tufts Health Plan considers the ICD-9 diagnoses code range 765 to 779.9 sick with the exception of the ICD-9 diagnoses codes listed in Exhibit 1.

Exhibit 3- Tufts Health Plan considers the following ICD-10 diagnosis code ranges Sick. These codes are effective on or after October 1, 2015:

A33 Tetanus neonatorum

P07.00 Extremely low birth weight newborn, unspecified weight P07.01 Extremely low birth weight newborn, less than 500 grams P07.02 Extremely low birth weight newborn, 500-749 grams P07.03 Extremely low birth weight newborn, 750-999 grams P07.10 Other low birth weight newborn, unspecified weight P07.14 Other low birth weight newborn, 1000-1249 grams P07.15 Other low birth weight newborn, 1250-1499 grams P07.16 Other low birth weight newborn, 1500-1749 grams P07.17 Other low birth weight newborn, 1750-1999 grams P07.18 Other low birth weight newborn, 2000-2499 grams

P07.20 Extreme immaturity of newborn, unspecified weeks of gestation

P07.21 Extreme immaturity of newborn, gestational age less than 23 completed weeks P07.22 Extreme immaturity of newborn, gestational age 23 completed weeks

P07.23 Extreme immaturity of newborn, gestational age 24 completed weeks P07.24 Extreme immaturity of newborn, gestational age 25 completed weeks P07.25 Extreme immaturity of newborn, gestational age 26 completed weeks P07.26 Extreme immaturity of newborn, gestational age 27 completed weeks P07.30 Preterm newborn, unspecified weeks of gestation

P07.31 Preterm newborn, gestational age 28 completed weeks P07.32 Preterm newborn, gestational age 29 completed weeks P07.33 Preterm newborn, gestational age 30 completed weeks

P07.23 Extreme immaturity of newborn, gestational age 24 completed weeks P07.24 Extreme immaturity of newborn, gestational age 25 completed weeks P07.34 Preterm newborn, gestational age 31 completed weeks

P07.35 Preterm newborn, gestational age 32 completed weeks P07.36 Preterm newborn, gestational age 33 completed weeks P07.37 Preterm newborn, gestational age 34 completed weeks P07.38 Preterm newborn, gestational age 35 completed weeks P07.39 Preterm newborn, gestational age 36 completed weeks P10.0 Subdural hemorrhage due to birth injury

P10.1 Cerebral hemorrhage due to birth injury P10.2 Intraventricular hemorrhage due to birth injury P10.3 Subarachnoid hemorrhage due to birth injury P10.4 Tentorial tear due to birth injury

P10.8 Other intracranial lacerations and hemorrhages due to birth injury P10.9 Unspecified intracranial laceration and hemorrhage due to birth injury P11.0 Cerebral edema due to birth injury

P11.1 Other specified brain damage due to birth injury P11.2 Unspecified brain damage due to birth injury P11.3 Birth injury to facial nerve

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P11.4 Birth injury to other cranial nerves P11.5 Birth injury to spine and spinal cord

P11.9 Birth injury to central nervous system, unspecified P13.0 Fracture of skull due to birth injury

P13.1 Other birth injuries to skull P13.2 Birth injury to femur

P13.3 Birth injury to other long bones

P13.8 Birth injuries to other parts of skeleton P13.9 Birth injury to skeleton, unspecified P14.0 Erb's paralysis due to birth injury P14.1 Klumpke's paralysis due to birth injury P14.2 Phrenic nerve paralysis due to birth injury P14.3 Other brachial plexus birth injuries

P14.8 Birth injuries to other parts of peripheral nervous system P14.9 Birth injury to peripheral nervous system, unspecified P15.0 Birth injury to liver

P15.1 Birth injury to spleen

P15.2 Sternomastoid injury due to birth injury P15.3 Birth injury to eye

P15.4 Birth injury to face

P15.5 Birth injury to external genitalia

P15.6 Subcutaneous fat necrosis due to birth injury P15.8 Other specified birth injuries

P15.9 Birth injury, unspecified

P19.0 Metabolic acidemia in newborn first noted before onset of labor P19.1 Metabolic acidemia in newborn first noted during labor

P19.2 Metabolic acidemia noted at birth P19.9 Metabolic acidemia, unspecified

P22.0 Respiratory distress syndrome of newborn P22.1 Transient tachypnea of newborn

P22.8 Other respiratory distress of newborn P22.9 Respiratory distress of newborn, unspecified P23.0 Congenital pneumonia due to viral agent P23.1 Congenital pneumonia due to Chlamydia P23.2 Congenital pneumonia due to staphylococcus

P23.3 Congenital pneumonia due to streptococcus, group B P23.4 Congenital pneumonia due to Escherichia coli

P23.5 Congenital pneumonia due to Pseudomonas

P23.6 Congenital pneumonia due to other bacterial agents P23.8 Congenital pneumonia due to other organisms P23.9 Congenital pneumonia, unspecified

P24.00 Meconium aspiration without respiratory symptoms P24.01 Meconium aspiration with respiratory symptoms

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symptoms

P24.21 Neonatal aspiration of blood with respiratory symptoms

P24.31 Neonatal aspiration of milk and regurgitated food with respiratory symptoms P24.81 Other neonatal aspiration with respiratory symptoms

P24.9 Neonatal aspiration, unspecified

P25.0 Interstitial emphysema originating in the perinatal period P25.1 Pneumothorax originating in the perinatal period

P25.2 Pneumomediastinum originating in the perinatal period P25.3 Pneumopericardium originating in the perinatal period

P25.8 Other conditions related to interstitial emphysema originating in the perinatal period

P26.0 Tracheobronchial hemorrhage originating in the perinatal period P26.1 Massive pulmonary hemorrhage originating in the perinatal period P26.8 Other pulmonary hemorrhages originating in the perinatal period P26.9 Unspecified pulmonary hemorrhage originating in the perinatal period P27.0 Wilson-Mikity syndrome

P27.1 Bronchopulmonary dysplasia originating in the perinatal period P27.8 Other chronic respiratory diseases originating in the perinatal period P27.9 Unspecified chronic respiratory disease originating in the perinatal period P28.0 Primary atelectasis of newborn

P28.10 Unspecified atelectasis of newborn

P28.11 Resorption atelectasis without respiratory distress syndrome P28.19 Other atelectasis of newborn

P28.2 Cyanotic attacks of newborn P28.3 Primary sleep apnea of newborn P28.4 Other apnea of newborn

P28.5 Respiratory failure of newborn P28.81 Respiratory arrest of newborn

P28.89 Other specified respiratory conditions of newborn P28.9 Respiratory condition of newborn, unspecified P29.0 Neonatal cardiac failure

P29.11 Neonatal tachycardia P29.12 Neonatal bradycardia

P29.2 Neonatal hypertension

P29.4 Transient myocardial ischemia in newborn P29.81 Cardiac arrest of newborn

P29.89 Other cardiovascular disorders originating in the perinatal period P29.9 Cardiovascular disorder originating in the perinatal period, unspecified P35.0 Congenital rubella syndrome

P35.1 Congenital cytomegalovirus infection

P35.2 Congenital herpesviral [herpes simplex] infection P35.3 Congenital viral hepatitis

P35.8 Other congenital viral diseases P35.9 Congenital viral disease, unspecified

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P36.0 Sepsis of newborn due to streptococcus, group B P36.10 Sepsis of newborn due to unspecified streptococci P36.19 Sepsis of newborn due to other streptococci P36.2 Sepsis of newborn due to Staphylococcus aureus P36.30 Sepsis of newborn due to unspecified staphylococci P36.39 Sepsis of newborn due to other staphylococci P36.4 Sepsis of newborn due to Escherichia coli P36.5 Sepsis of newborn due to anaerobes P36.8 Other bacterial sepsis of newborn P36.9 Bacterial sepsis of newborn, unspecified P37.0 Congenital tuberculosis

P37.1 Congenital toxoplasmosis

P37.2 Neonatal (disseminated) listeriosis P37.3 Congenital falciparum malaria P37.4 Other congenital malaria

P37.8 Other specified congenital infectious and parasitic diseases P37.9 Congenital infectious or parasitic disease, unspecified P38.1 Omphalitis with mild hemorrhage

P38.9 Omphalitis without hemorrhage P39.0 Neonatal infective mastitis

P39.2 Intra-amniotic infection affecting newborn, not elsewhere classified P39.3 Neonatal urinary tract infection

P39.4 Neonatal skin infection

P39.8 Other specified infections specific to the perinatal period P39.9 Infection specific to the perinatal period, unspecified

P50.0 Newborn affected by intrauterine (fetal) blood loss from vasa previa P50.1 Newborn affected by intrauterine (fetal) blood loss from ruptured cord P50.2 Newborn affected by intrauterine (fetal) blood loss from placenta P50.3 Newborn affected by hemorrhage into co-twin

P50.4 Newborn affected by hemorrhage into maternal circulation

P50.5 Newborn affected by intrauterine (fetal) blood loss from cut end of co-twin's _cord P50.8 Newborn affected by other intrauterine (fetal) blood loss

P50.9 Newborn affected by intrauterine (fetal) blood loss, unspecified P51.0 Massive umbilical hemorrhage of newborn

P51.8 Other umbilical hemorrhages of newborn P51.9 Umbilical hemorrhage of newborn, unspecified

P52.0 Intraventricular (nontraumatic) hemorrhage, grade 1, of newborn P52.1 Intraventricular (nontraumatic) hemorrhage, grade 2, of newborn P52.21 Intraventricular (nontraumatic) hemorrhage, grade 3, of newborn P52.22 Intraventricular (nontraumatic) hemorrhage, grade 4, of newborn P52.3 Unspecified intraventricular (nontraumatic) hemorrhage of newborn P52.4 Intracerebral (nontraumatic) hemorrhage of newborn

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P52.6 Cerebellar (nontraumatic) and posterior fossa hemorrhage of newborn P52.8 Other intracranial (nontraumatic) hemorrhages of newborn

P52.9 Intracranial (nontraumatic) hemorrhage of newborn, unspecified P53 Hemorrhagic disease of newborn

P54.0 Neonatal hematemesis

P54.1 Neonatal melena

P54.2 Neonatal rectal hemorrhage

P54.3 Other neonatal gastrointestinal hemorrhage P54.4 Neonatal adrenal hemorrhage

P54.6 Neonatal vaginal hemorrhage

P54.8 Other specified neonatal hemorrhages P54.9 Neonatal hemorrhage, unspecified P55.0 Rh isoimmunization of newborn P55.1 ABO isoimmunization of newborn P55.8 Other hemolytic diseases of newborn P55.9 Hemolytic disease of newborn, unspecified P56.0 Hydrops fetalis due to isoimmunization

P56.90 Hydrops fetalis due to unspecified hemolytic disease P56.99 Hydrops fetalis due to other hemolytic disease P57.0 Kernicterus due to isoimmunization

P57.8 Other specified kernicterus P57.9 Kernicterus, unspecified

P58.0 Neonatal jaundice due to bruising P58.1 Neonatal jaundice due to bleeding P58.2 Neonatal jaundice due to infection P58.3 Neonatal jaundice due to polycythemia

P58.41 Neonatal jaundice due to drugs or toxins transmitted from mother P58.42 Neonatal jaundice due to drugs or toxins given to newborn

P58.5 Neonatal jaundice due to swallowed maternal blood

P58.8 Neonatal jaundice due to other specified excessive hemolysis P58.9 Neonatal jaundice due to excessive hemolysis, unspecified P59.0 Neonatal jaundice associated with preterm delivery P59.1 Inspissated bile syndrome

P59.20 Neonatal jaundice from unspecified hepatocellular damage P59.29 Neonatal jaundice from other hepatocellular damage P59.3 Neonatal jaundice from breast milk inhibitor

P59.8 Neonatal jaundice from other specified causes P60 Disseminated intravascular coagulation of newborn P61.0 Transient neonatal thrombocytopenia

P61.1 Polycythemia neonatorum

P61.2 Anemia of prematurity

P61.3 Congenital anemia from fetal blood loss

P61.4 Other congenital anemias, not elsewhere classified P61.5 Transient neonatal neutropenia

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P61.6 Other transient neonatal disorders of coagulation P61.8 Other specified perinatal hematological disorders P61.9 Perinatal hematological disorder, unspecified

P70.0 Syndrome of infant of mother with gestational diabetes P70.1 Syndrome of infant of a diabetic mother

P70.2 Neonatal diabetes mellitus P70.3 Iatrogenic neonatal hypoglycemia P70.4 Other neonatal hypoglycemia

P70.8 Other transitory disorders of carbohydrate metabolism of newborn P70.9 Transitory disorder of carbohydrate metabolism of newborn, unspecified P71.0 Cow's milk hypocalcemia in newborn

P71.1 Other neonatal hypocalcemia

P71.2 Neonatal hypomagnesemia

P71.3 Neonatal tetany without calcium or magnesium deficiency P71.4 Transitory neonatal hypoparathyroidism

P71.8 Other transitory neonatal disorders of calcium and magnesium metabolism P71.9 Transitory neonatal disorder of calcium and magnesium metabolism, unspecified P72.0 Neonatal goiter, not elsewhere classified

P72.1 Transitory neonatal hyperthyroidism

P72.2 Other transitory neonatal disorders of thyroid function, not elsewhere classified P72.8 Other specified transitory neonatal endocrine disorders

P72.9 Transitory neonatal endocrine disorder, unspecified P74.0 Late metabolic acidosis of newborn

P74.1 Dehydration of newborn

P74.2 Disturbances of sodium balance of newborn P74.3 Disturbances of potassium balance of newborn P74.4 Other transitory electrolyte disturbances of newborn P74.5 Transitory tyrosinemia of newborn

P74.6 Transitory hyperammonemia of newborn

P74.8 Other transitory metabolic disturbances of newborn P74.9 Transitory metabolic disturbance of newborn, unspecified

P76.0 Meconium plug syndrome

P76.2 Intestinal obstruction due to inspissated milk P76.8 Other specified intestinal obstruction of newborn P76.9 Intestinal obstruction of newborn, unspecified P77.1 Stage 1 necrotizing enterocolitis in newborn P77.2 Stage 2 necrotizing enterocolitis in newborn P77.3 Stage 3 necrotizing enterocolitis in newborn P77.9 Necrotizing enterocolitis in newborn, unspecified P78.0 Perinatal intestinal perforation

P78.1 Other neonatal peritonitis P78.3 Noninfective neonatal diarrhea P78.81 Congenital cirrhosis (of liver) P78.82 Peptic ulcer of newborn

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P78.83 Newborn esophageal reflux

P78.89 Other specified perinatal digestive system disorders P78.9 Perinatal digestive system disorder, unspecified P80.0 Cold injury syndrome

P80.8 Other hypothermia of newborn P80.9 Hypothermia of newborn, unspecified P81.0 Environmental hyperthermia of newborn

P81.8 Other specified disturbances of temperature regulation of newborn P81.9 Disturbance of temperature regulation of newborn, unspecified P83.1 Neonatal erythema toxicum

P83.2 Hydrops fetalis not due to hemolytic disease P83.30 Unspecified edema specific to newborn P83.39 Other edema specific to newborn P83.6 Umbilical polyp of newborn

P83.8 Other specified conditions of integument specific to newborn P83.9 Condition of the integument specific to newborn, unspecified

P84 Other problems with newborn

P90 Convulsions of newborn

P91.0 Neonatal cerebral ischemia

P91.1 Acquired periventricular cysts of newborn P91.2 Neonatal cerebral leukomalacia

P91.3 Neonatal cerebral irritability P91.4 Neonatal cerebral depression

P91.5 Neonatal coma

P91.60 Hypoxic ischemic encephalopathy [HIE], unspecified P91.61 Mild hypoxic ischemic encephalopathy [HIE]

P91.62 Moderate hypoxic ischemic encephalopathy [HIE] P91.63 Severe hypoxic ischemic encephalopathy [HIE]

P91.8 Other specified disturbances of cerebral status of newborn P91.9 Disturbance of cerebral status of newborn, unspecified P92.01 Bilious vomiting of newborn

P92.09 Other vomiting of newborn

P92.1 Regurgitation and rumination of newborn P92.2 Slow feeding of newborn

P92.3 Underfeeding of newborn P92.4 Overfeeding of newborn

P92.5 Neonatal difficulty in feeding at breast P92.6 Failure to thrive in newborn

P92.8 Other feeding problems of newborn P92.9 Feeding problem of newborn, unspecified

P93.0 Grey baby syndrome

P93.8 Other reactions and intoxications due to drugs administered to newborn P94.0 Transient neonatal myasthenia gravis

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P94.2 Congenital hypotonia

P94.8 Other disorders of muscle tone of newborn P94.9 Disorder of muscle tone of newborn, unspecified P96.0 Congenital renal failure

P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction P96.2 Withdrawal symptoms from therapeutic use of drugs in newborn P96.3 Wide cranial sutures of newborn

P96.5 Complication to newborn due to (fetal) intrauterine procedure P96.89 Other specified conditions originating in the perinatal period P96.9 Condition originating in the perinatal period, unspecified

R78.81 Bacteremia

Additional payment for newborns requiring sick newborn care is contingent upon the newborn being enrolled for family coverage.

Note: Sick newborn(s) must be enrolled with Tufts Health Plan and an inpatient notification sent to Tufts Health Plan separately for sick-related charges to appropriately adjudicate beyond the mother’s discharge date.

Facilities with a Non-DRG Arrangement

Tufts Health Plan splits all inpatient claims when the admission date and discharge date fall into different calendar years. If the date of admission on the claim is a different calendar year than the discharge date (e.g., 12/31/11 -1/2/12), Tufts Health Plan will split services into separate claims to process. Separate claim numbers will be assigned to each claim that has been split from the original claim. Payment is based on the contractual rate on the date of admission.

Multiple Diagnoses

Tufts Health Plan accepts multiple diagnoses submitted on an inpatient room and board claim. If both well and sick diagnoses are submitted, Tufts Health Plan will use a sick diagnosis to process the claim, even if it is not the primary diagnosis submitted.

Birthweight

Birthweight is needed for correct claims processing and accurate reimbursement of newborn inpatient claims and should always be submitted in accordance with industry standards on the UB04 claim form. In the event that birthweight is not submitted or available on a claim, Tufts Health Plan will apply a birthweight to the claim in accordance with the condition related diagnoses submitted on the claim as follows:

Diagnosis Codes Birth Weight (grams)

764.00 764.10 764.20 764.90 765.00 765.10 2,500 764.01 764.11 764.21 764.91 765.01 765.11 499 764.02 764.12 764.22 764.92 765.02 765.12 749 764. 03 764.13 764.23 764.93 765.03 765.13 999 764.04 764.14 764.24 764.94 765.04 765.14 1,249 764.05 764.15 764.25 764..95 765.05 765.15 1,499 764.06 764.16 764.26 764.96 765.06 765.16 1,749 764.07 764.17 764.27 764.97 765.07 765.17 1,999 764.08 764.18 764.28 764.98 765.08 765.18 2,499 764.09 764.19 764.29 764.99 765.09 765.19 2,500

If no condition related diagnosis exists on the claim, then Tufts Health Plan will apply a birthweight in accordance with the following Supplementary Classification diagnoses submitted on the claim as follows:

V21.30 2,500

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V21.32 999

V21.33 1,499

V21.34 1,999

V21.35 2,499

If none of the above are available, Tufts Health Plan will utilize 2,500 grams as the default birthweight to process newborn inpatient claims.

The following ICD-10 diagnosis codes are effectiveon or after October 1, 2015:

ICD-10 Diagnosis Codes Birth Weight (grams)

P05.00 P05.10 P07.00 P07.10 Unspecified weight P05.01 P05.11 P07.01 Less than 500 P05.02 P05.12 P07.02 500-749 P05.03 P05.13 P07.03 750- 999 P05.04 P05.14 P07.14 1,000-1,249 P05.05 P05.15 P07.15 1,250-1,499 P05.06 P05.16 P07.16 1,500-1,749 P05.07 P05.17 P07.17 1,750-1,999 P05.08 P05.18 P07.18 2,000-2,499

If none of the above is available, Tufts Health Plan will utilize 2,500 grams as the default birthweight to process newborn inpatient claims.

COMPENSATION/REIMBURSEMENT

Claims are subject to payment edits that are updated at regular intervals and generally based on Centers for Medicare & Medicaid Services (CMS), specialty society guidelines, drug manufacturers’ package label inserts and National Correct Coding Initiative (CCI).

Compensation for inpatient treatment and related services corresponds to the Tufts Health Plan contracted rate per case and/or any other contractual arrangement. Refer to your current contract for details.

Payment methodology used for a hospital claim is determined by the methodology in place at the time of the member's admission except in those situations when member enrollment occurred after the admission date. In these instances payment methodology will be determined by the methodology in place at the time of enrollment.

The inpatient compensation rate, regardless of payment methodology, is inclusive of all services supplied by the facility, including, but not limited to:

 Ancillary services  Diagnostic services  Preadmission testing

 Anesthesia care  Medication and supplies  Radiology/Imaging*

 Appliances and equipment

 Bedside equipment  Nursing Care/Services Observation  Recovery room services Therapeutic items (drugs and biologicals)

*Routine preadmission testing performed in the three days prior to an inpatient admission is not compensated separately.

Facilities with a Non-DRG Arrangement

Tufts Health Plan determines compensation for inpatient services based on notification and authorization of days.

Inpatient Neonatal and Pediatric Critical Care Services

Tufts Health Plan does not compensate for more than one neonatal or pediatric critical care service per member per same date of service.

Neonatal Intensive Care Services

Tufts Health Plan does not compensate for more than one neonatal intensive care service per same date of service by the same provider.

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Neonatal and Pediatric Critical Care

Tufts Health Plan does not compensate for initial neonatal and pediatric critical care services if the member received inpatient critical care services the previous day.

Newborn Care Services

Tufts Health Plan does not compensate for initial hospital or birthing center care services if the member received initial or subsequent newborn care services the previous day.

Diagnosis Related Grouping (DRG)

Tufts Health Plan incorporates the Diagnosis Related Grouping (DRG) methodology when processing inpatient claims. Tufts Health Plan currently applies the Diagnosis Related Groups Definition outlined in your provider contract to assign a DRG to an inpatient claim.

Tufts Health Plan will determine the compensation rate for the inpatient hospital claim based on the DRG assigned according to the methodology described above, regardless of the DRG submitted on the claim.

Tufts Health Plan uses the following data from the inpatient claim to assign a DRG:

 ICD-CM procedure code(s)

 ICD-CM diagnosis code(s)

 Member gender

 Member date of birth

 Birthweight, when applicable

 POA

Claims assigned to APR DRGs 950-956 will deny. The Hospital may resubmit corrected claims timely, in accordance with Tufts Health Plan’s standard payment policies.

Examples of APR DRG claims that will deny include the following:

 DRG 955: Principal Diagnosis Invalid as Discharge Diagnosis

 DRG 956: Un-groupable

Note: If a member terminates with Tufts Health Plan while receiving inpatient services, the facility payment will be adjusted accordingly, up to and including the last effective date of the member’s coverage.

If member coverage begins while the member is receiving inpatient services, the facility payment will be adjusted accordingly starting with the first effective date of member’s coverage.

Transfer Policy to Another Acute Facility

If a member is transferred, payment may be prorated.

Hospital Acquired Conditions (HAC)- DRG Arrangement

Diagnoses for hospital acquired conditions will not be included in the DRG calculation. Compensation could vary, based on the recalculated DRG.

Serious Reportable Events (“Never Events”)

The National Quality Forum (NQF) defines “Never Events” as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility. Tufts Health Plan’s longstanding policy has been to deny or retract payment for care related to procedures which meet the definition of a “Never Event” once they have been identified.

 Tufts Health Plan will not compensate providers or permit providers to bill members for services related to the occurrence of “Never Events.”

 For a list of “Never Events” refer to the National Quality Forum.

Tufts Health Plan’s Clinical Quality Improvement Department works directly with the involved provider to review the clinical event, identify opportunities for quality improvement. Refer any outstanding payment issues to the appropriate Tufts Health Plan department.

To report a “Never Event”, fax the report to Tufts Health Plan’s Clinical Quality Improvement department at 617.673.0973.

Explanation of Payment (EOP)

The EOP provides information on the status of the claim(s) submitted to Tufts Health Plan. The EOP indicates status of claims payments, denials and pending claims.

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Electronic Remittance Advice (ERA)

The HIPAA compliant 835 ERA is an EDI transaction that providers may request to electronically post paid and denied claims information to their accounts receivable system.

ADDITIONAL RESOURCES

Obstetrics/Gynecology Professional Payment Policy Surgery Professional Payment Policy

DOCUMENT HISTORY

 January 2016: Added newborn coverage information for Tufts Health Freedom Plan members

 September 2015: Template conversion, template updates

 March 2015: Removed policy regarding for per-day initial hospital or birthing center care E&M admitted and discharged on the same date, effective for dates of service on or after January 1, 2015 as it no longer applies, template updates.

 November 2014: Added policy regarding for per-day initial hospital or birthing center care E&M admitted and discharged on the same date, effective for dates of service on or after January 1, 2015, template updates.

 September 2014: Added information regarding payment methodology in situations when member enrollment occurred after the admission date, template updates

 July 2014: Updated ICD-10 implementation language, template updates

 May 2014: Added policies about neonatal and pediatric critical care, neonatal intensive care and newborn care services effective for dates of service on or after July 1, 2014, updated information regarding obstetrical admissions, template updates

 November 2013: Added information about preadmission testing, effective for dates of service on or after January 1, 2013, information regarding Diagnosis Related Grouping (DRG) methodology, template updates.

 September 2013: Template conversion

 July 2013: Added ICD-10 diagnosis codes, clarified circumcision information, template updates.

 June 2012: Template updates, added birthweight information.

 March 2012: Updated CareLink disclaimer language.

 February 2012: Policy reviewed, template updates made.

 November 2011: Template updates, no content changes.

 October 2010: Added information regarding the non-coverage of custodial newborn care. Added information regarding Preventive Services.

 January 2009: Deleted CPT procedure codes 99431, 99432, 99433, 99435, 99436 & 99440 and replaced with 99460, 99461, 99462, 99463, 99464 & 99465.

 February 2008: Revised general benefit information with self-service channels information.

 May 2007: Added professional services information and clarified well and sick newborn criteria.

AUDIT AND DISCLAIMER INFORMATION

Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this payment policy. If such an audit determines that your office/facility did not comply with this payment policy, Tufts Health Plan will expect your office/facility to refund all payments related to non-compliance. For more information about Tufts Health Plan’s audit policies, refer to our website.

This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is neither a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, and adherence to plan policies and procedures and claims editing logic. This policy does not apply to Tufts Medicare Preferred HMO, Tufts Health Plan Senior Care Options, Tufts Health Public Plans or the Private Health Care Systems (PHCS) network (also known as Multiplan). This policy applies to CareLink for providers in Massachusetts and Rhode Island service areas. Providers in the New Hampshire service area are subject to Cigna’s provider agreements with respect to CareLink members.