Reimbursement

Obtaining Reimbursement

Provider may not bill or seek payment from members or BHN for covered services with the exception of billing and seeking payment from members for applicable copayments, coinsurance, deductibles, and services in excess of benefit limits as specified in the member’s benefit plan and as outlined in the provider agreement. In the event that the service is determined not to be a covered service, provider may bill the member, so long as the member received notice prior to the service being rendered that he/she would be responsible for such charges.

Remittance Advice

To view Remittance Advice (RA) login to provider’s account and navigate to ERA Download.

Search claims using Member ID, Patient Account Number, BHN Claim ID and other such criteria.

MagnaCare products:

Log into the website or call Provider Services at 800-352-6465.

Create products:

Log into the website or call Provider Services at 1-844-427-3878.

Expected Reimbursement Timeframe

BHN issues payments daily to providers based on client funding. Clean claims shall be paid by either BHN or payor, as applicable, per the terms of the Provider Agreement. In the event that BHN determines that a claim is incomplete, inaccurate, or subject to Coordination of Benefits, BHN or Payor shall remit payment within 45 days of receipt of all records and information necessary for proper claims adjudication. BHN nor payor shall be required to pay a claim where records and information have not been received within one hundred and eighty (180) days of service date.

Surgery Standard

Multiple ambulatory surgery procedures shall be reimbursed at one hundred percent (100%) of the contracted rate for the most expensive procedure, fifty percent (50%) of the contracted rate for the second most expensive procedure, and twenty-five percent (25%) of the contracted rate for each additional procedure. If all services run through the Grouper are ungroupable, then the total claim is paid at the ungroupable case rate. If one (1) or more services are matched to groups, then ungroupable services are to be denied as inclusive of the matched procedure(s).

The BHN ASC groupers can be found here.

Allied Professionals Standard

Allied Professionals, including, but not limited to, Nurse Practitioners, Physician Assistants, and PsyDs, will be paid at seventy percent (70%) of the BHN maximum default fee schedule.

Physical Therapy Standard

Physical therapy services will be bundled per standard methodology and reimbursed as a single episode of care regardless of the number of modalities billed.

Ceiling Provision Standard

For all covered services, reimbursement will be the lesser of the BHN allowed amount or one hundred percent (100%) of billed charges.

Urgent Care Standard

Urgent Care services are to treat non-life threatening conditions and minor medical conditions. Global fee allowance for Urgent Care services includes all services rendered during that episode of care, including but not limited to the following services: professional, facility, laboratory, pathology, radiology, diagnostic, therapeutic, non-preventable vaccinations and all surgical dressings, drugs, splints, IV therapy, casts and other supplies.

All other non-urgent care, routine service, preventative care and/or immunization cannot be billed in conjunction with an urgent care visit.

Inpatient Transfers

BHN will reduce DRG allowances when an admitted member is transferred to a different hospital resulting in a subsequent admission. All transfers are subject to evaluation on a case-by-case basis by the BHN Medical Management Team.

Member transfers will not be predicated on arbitrary, capricious, or unreasonable discrimination because of race, color, religion, national origin, age, sex, physical condition, disability, sexual orientation, gender identity or expression, genetic information, veteran status, economic or insurance status, or ability to pay.

All transfers will be preceded by member (or personal representative) education regarding risks, need and benefits of the transfer. This information will be documented in the medical records.

Reimbursement to the Network hospital that transferred the patient will be reimbursed on a calculated per diem rate.

For hospitals contracted at MS DRG groupers, the calculated per diem is equal to the outlier threshold for non-transfer cases, divided by the geometric mean length of stay for the DRG, multiplied by a number equal to the length of stay for the case and not to exceed the full DRG payment.
Payment to hospitals excluded from DRG reimbursement are paid at the BHN contracted rate.

When a member is transferred to a different hospital within the same hospital system, BHN may pend or deny the initial admission and reimburse only the second admission. Emergency room and ambulance fees related to a transfer will be denied.

Never Events

Never Events, and all associated services related to the Never Event, will not be reimbursed.

Never Events are defined as adverse events or errors in medical care that are clearly identifiable, preventable and present serious consequences to patients. This includes, but may not be limited to, hospitalacquired conditions, incorrect procedures, procedures performed on an incorrect body part or wrong person.

Never Events are not considered medically necessary as they are not required to diagnose or treat an illness, injury, disease or its symptoms and are not consistent with generally accepted standards of medical practice.

Providers involved in follow-up care necessitated by the occurrence of a Never Event but were not responsible for the occurrence will be reimbursed.

Observation

Observation is a well-defined set of specific, clinically appropriate services, which include ongoing assessment, reassessment and short-term treatment interventions that are required to make a decision whether members will require further treatment as hospital inpatients, or if they can be discharged from the hospital for treatment as an outpatient in the community.

Claims submitted with charges for observation services are subject to medical necessity review and potential denial of payment.

Observation services billed at less than eight (8) units will be reduced to the next level and reimbursed at emergency room or ambulatory surgery rate. Observation services billed at greater than forty eight (48) units will be denied for review by BHN Medical Management team. This may require that the network hospital submit medical records or additional information.

When emergency department services precede an observation stay, the emergency department services are considered inclusive to the observation services.

All observation services within three (3) days of an inpatient stay are considered inclusive to that inpatient stay.

Readmission

BHN may pend or deny a claim and request medical records or additional information if a claim meets any of the following conditions: same day readmissions for a related condition, planned readmission, or unplanned readmission within thirty (30) days after a previous discharge.