This FAQ explains the new Independence Blue Cross (IBX) policy regarding Reimbursement for Emergent Inpatient Admissions. The policy only applies to Medicare Advantage plans.
Note: This document will be updated as additional information becomes available.
1. What lines of business does the Reimbursement for Emergent Inpatient Admissions policy apply to?
This policy applies only to Medicare Advantage members.
2. What is the effective date of the policy?
This new policy goes into effect on March 5, 2026.
3. Does this change the current process for notifying IBX of an emergent inpatient admission via PEAR PM within two business days of the admission?
We are updating our notification process to provide hospitals with greater flexibility. Hospitals are no longer required to notify IBX of an inpatient admission within two business days. Instead, notification may now be submitted after the member is discharged from an emergent admission that lasts up to and including 5 days.
4. When should hospitals submit the initial authorization request?
Hospitals are requested to submit the initial authorization request after the member is discharged, covering the inpatient stay up to and including day 5.
5. What clinical information is required at the time of the initial request?
The initial authorization request must include the complete clinical picture for the entire admission period up to and including day 5. This includes all relevant documentation necessary to determine medical necessity and ensure accurate reimbursement.
6. Can hospitals submit the initial authorization request before the member is discharged?
Hospitals may submit the initial authorization request before the member is discharged; however, we encourage hospitals to submit after the member is discharged, covering the inpatient stay up to and including day 5. Submitting the request after the member is discharged helps reduce avoidable delays that may occur when documentation is incomplete or missing early in the stay.
7. Does this process apply to all inpatient stays?
No, it is only for Medicare Advantage members when the stay is paid according to a diagnostic-related group (DRG)/Case rate reimbursement methodology and when the admission is 5 days or less. Per Diem reimbursement methodologies are not included in this new reimbursement policy.
8. What is the process for Medicare Advantage emergent inpatient admissions that are 6 days or greater?
There is no change in the existing process for stays of 6 days or greater. However, outlier stays may be subject to concurrent review.
9. How will IBX determine the amount of observation payment under the new payment policy?
Observation rates are set forth in your hospital agreement and will be applied to the case based on the medical records submitted.
10. Do all observation claims now require authorization?
No, there are no changes to the submission process for an observation claim. Observation stays do not require authorization or notification.
11. How does this new policy help hospitals?
It helps streamline workflows by removing multiple administrative steps and ensuring faster payment.
Prior to the policy’s effective date, Medicare Advantage emergent inpatient claims of 5 days or less were denied when inpatient criteria were not met. In those cases, hospitals were required to resubmit the claim as outpatient/observation to receive payment.
Under the new policy, these steps are no longer required. Hospitals will no longer need to:
- Notify IBX of the emergent inpatient admission of a Medicare Advantage member within two business days,
- Submit medical records prior to discharge, or
- Rebill the claim as outpatient/observation if necessary.
12. What member cost-share will be applied to the claim?
Regardless of the payment level, hospitals should charge members the inpatient cost-sharing amount when IBX has approved coverage for an inpatient level of care.
13. How will a hospital be notified when an emergent inpatient admission up to 5 inpatient days does or does not meet inpatient level of payment criteria?
The payment determination will be displayed within the Authorization Search transaction in the Practice Management (PM) application of the Provider Engagement, Analytics & Reporting (PEAR) portal. Explanations of payment at the observation rate will also include messaging.
14. Can hospitals request a discussion with an IBX Medical Director?
Hospitals will still be able to request a review of payment, including the option to discuss the case with one of the IBX Medical Directors, and to dispute the application of the payment policy if they believe the medical records meet InterQual® acute inpatient criteria. It is important to note that these discussions and reviews will not be focused on coverage criteria when the acute inpatient level of care has been approved for coverage.
15. What if a hospital would like to request a payment review prior to discharge and/or claim submission?
We encourage hospitals to wait until all clinical information has been submitted. Receiving that information after discharge allows IBX to conduct a more complete and accurate review. This approach helps ensure payment determinations are based on all relevant information.
16. How can a hospital dispute the payment determination?
If you disagree with the payment determination, you may request a review of payment, which includes the option to discuss the case with one of the IBX Medical Directors (as noted in question 14). Before making that request, please ensure that all the necessary clinical information has been submitted after discharge. Note that each admission will be limited to one call with an IBX Medical Director. After your claim has been processed, you may send in a payment dispute request via the Claim Search transaction in PEAR PM.
17. How does this reimbursement policy interact with the existing Hospital Manual, and which guidelines take precedence when there is a conflict?
For purposes of payment determination under this policy, the criteria, definitions, and requirements outlined here take precedence over those in the Hospital Manual, including its definition of admission review. The Hospital Manual’s definition of admission may still apply for operational or payment processes not governed by this policy. The Hospital Manual will be updated as needed to ensure alignment; however, until those revisions are issued, this payment policy shall supersede the Hospital Manual where conflicts arise.
If you have additional questions regarding this new policy, please email eiapolicyinquiries@ibx.com.