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August 13, 2019
Community First Health Plans is rescinding the following provider notice and the addition of this provision in our provider manuals for all lines of business. Please disregard the following notice and all of its content as it no longer applies.
EFFECTIVE SEPTEMBER 1, 2019
NOTICE OF PROVISION ADDED TO ALL FACILITY AGREEMENTS VIA THE CFHP PROVIDER MANUAL
CFHP is adding the following provision to Provider Manuals for ALL lines of business:
Two Midnight Rule
CFHP does not cover one night stays at Facility as an “inpatient” stay. An admission is considered “inpatient” if the admitting practitioner expected the patient to require a stay at the Facility that crosses two midnight's AND the medical record supports that reasonable expectation. An admission is considered “outpatient” for stays that do not meet this two-midnight standard. This Utilization Management rule includes admission to any level of acute or sub-acute care, hospice, skilled nursing facilities, rehabilitation, admission and all other inpatient facility type admission.
• Inpatient facility to facility transfers
• NICU/Special Care Nursery admissions
• Elective inpatient admissions
• Intraoperative Monitoring
**Please note that no additional reimbursement will be provided for robotic assisted surgeries
***All emergent inpatient admissions require notification by the close of the next business
• Global OB 2 day vaginal and 4 day C-Section deliveries and Observations stays.
If a stay is not reasonably expected to span two or more midnight's, CFHP will assess the claim
to determine if an exception exists that would nonetheless make a payment appropriate,
1. If the procedure is on the Secretary’s list of “inpatient only” procedures (identified
through annual regulation)
2. If the procedure is a CMS-identified, national exception to the Two-Midnight benchmark
3. If the admission otherwise qualifies for a case-by-case exception to the Two-Midnight
benchmark because the medical record documentation supports the admitting
physician/practitioner’s judgment that the beneficiary required hospital care on an
inpatient basis despite the lack of a Two-Midnight expectation. CFHP will note CMS’
expectation that stays under 24 hours would rarely qualify for an exception to the Two-
4. One day stays at Behavioral Health Facilities will be paid the lesser of a contracted
Observation rate or at 75% of the contracted Per Diem rate.
5. All observation stays, no matter the type, do not require authorization.
For future reference, this provision will be placed in the Provider Manuals listed below. CFHP is currently re-writing all provider manuals; for references on or before August 15th, the new language can be located on the noted pages:
On or after September 1, 2019 providers who do not adhere to this rule may have claims denied.
Director, Network Management
Phone: (210) 358-6180