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 is effective 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?
Yes, the 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. This update is intended to give hospitals greater flexibility.
4. When should hospitals submit notification to IBX of an inpatient admission? What happens if the stay extends to day 6?
Hospitals should submit notification to IBX after the member is discharged from an inpatient stay. The submission should include clinical documentation for up to and including day 5. If the stay extends to day 6, hospitals can wait and submit all required clinical information after the patient is discharged.
5. What clinical information should be submitted at the time of notification?
Hospitals must submit 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 notification before the member is discharged?
Yes, hospitals may submit notification before the member is discharged. However, we encourage hospitals to submit after the member is discharged so we have a complete picture of the admission. This also helps reduce avoidable delays that may occur when documentation is incomplete or missing early in the stay. All submissions should include clinical documentation for up to and including day 5.
7. Does this policy apply to all inpatient stays?
The policy only applies to 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.
This policy does not apply to the following:
- Cases involving an unexpected death, Centers for Medicare & Medicaid Services (CMS) inpatient-only procedures, and newly initiated mechanical ventilations. In those instances, the hospital will be reimbursed at the acute inpatient DRG rate.
- Behavioral health admissions, long-term acute care inpatient admissions, and acute rehabilitation confinements.
8. How will the amount of observation payment under the new payment policy be determined?
The amount of observation payment will be determined in accordance with the applicable terms of the hospital’s agreement with IBX. The contracted observation rates will be applied based on a review of the clinical documentation submitted and consistent with the provisions of the agreement.
9. 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.
10. How does this new policy make the notification and payment process easier?
The new policy streamlines administrative workflows by reducing multiple administrative steps and allowing for more efficient review and payment. Prior to the new policy, Medicare Advantage emergent inpatient stays of 5 days or less were denied when inpatient criteria were not met, requiring hospitals to resubmit the claim as outpatient/observation to receive payment.
Under the new policy, hospitals no longer need to:
- Notify IBX of a Medicare Advantage emergent inpatient admission within two business days,
- Submit medical records prior to discharge, or
- Rebill the claim as outpatient/observation if necessary.
11. How will hospitals be notified whether an emergent inpatient admission up to 5 days meets inpatient payment criteria?
The payment determination will be available through the Authorization Search transaction in the Practice Management (PM) application of the Provider Engagement, Analytics & Reporting (PEAR) portal. When payment is applied at the observation rate, an explanation message will also be provided.
12. Can hospitals still request a discussion with an IBX Medical Director?
Yes, hospitals may request a review of a payment determination, including the option to discuss the case with an IBX Medical Director.
13. 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.
14. 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 12). 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.
If you have additional questions regarding this new policy, please email
eiapolicyinquiries@ibx.com.