Reimbursement Guidelines: Payment Window and Services Preceding Inpatient Admission

Key Details:

Effective November 1, 2023

The following payment window reimbursement guidelines apply to services that are rendered by the hospital or an entity that is wholly owned or operated by the hospital. The three-day (or one-day) payment window does not apply if:

The hospital and the physician’s office or other entity are both owned by a third party, such as a health system.
The hospital is not the sole or 100 percent owner of the entity.

Texas Medicaid inpatient hospital Providers must submit, as part of the client’s inpatient hospital claim, all related professional and outpatient services that were rendered on the date of the client’s inpatient admission or one of the following dates immediately before admission:

Within three calendar days before the client’s inpatient admission for hospitals that receive DRG reimbursement, with the exception of children’s hospitals.
Within one calendar day before the client’s inpatient admission for hospitals that receive reimbursement other than DRG.
Within one calendar day before the client’s inpatient admission to children’s hospitals.

Professional and outpatient services that must be submitted as part of the inpatient hospital claim include the following services if they are rendered by the hospital or an entity that is wholly owned or operated by the hospital:

Diagnostic services. Diagnostic services include outpatient laboratory and radiology services that are related to the inpatient admission and submitted by physicians and outpatient hospital Providers. Affected services will include the total and technical components. The professional interpretation component will not be included in the payment windows identified above.
Non-diagnostic services. Non-diagnostic services include surgeries and other non-diagnostic procedures and services that are related to the inpatient admission and submitted by physicians, outpatient hospitals, or other Providers.

Important: Related professional and outpatient services that were rendered within the specified time frames must be submitted on the inpatient hospital claim and not on an outpatient hospital claim. An outpatient hospital claim for these services will be denied as part of the payment for the inpatient hospital stay.

Source Link: Texas Medicaid: Provider Procedures Manual

3.7.4.19 Payment Window Reimbursement Guidelines

3.7.4.19.1 Guidelines for Services Preceding an Inpatient Admission

Next steps for Providers:

Providers should share this communication with their staff.

Community First Resources: