Medicare inpatient admissions billing
When coverage begins or ends during a hospital admission, plan responsibility is established by the Centers for Medicare & Medicaid Services (CMS) in chapter 4 of the Medicare Managed Care Manual, "Benefits and Beneficiary Protections." Priority Health Medicare administers coverage as follows.
Inpatient facility charges
The plan in which a Medicare member is enrolled on the date of admission to the hospital is responsible for payment for inpatient hospital services from the point of admission to the point of discharge, even if the member changes to a different plan during the time he or she is in the hospital.
Covered inpatient services
For more information on coverage for inpatient services as defined by the Centers for Medicare & Medicaid Services (CMS), see the Medicare Benefit Policy Manual, section 1, chapter 1, "Inpatient Hospital Services Covered Under Part A." Services include:
- Bed and board
- Nursing services and other related services
- Use of hospital
- Medical social services
- Drugs
- Biologicals
- Supplies, appliances and equipment
- Certain other diagnostic or therapeutic services
- Medical or surgical services provided by interns/residents-in-training
- Transportation services, including transport by ambulance
- Nonphysician services which must be provided directly or arranged by the hospital
Professional services charges
The plan in which the member is enrolled is responsible for payment of professional hospital services through the member's date of disenrollment (termination of coverage).
If the member has not yet been discharged and becomes covered by a new Medicare plan, the new plan is responsible for charges from the member's effective date of coverage to the point of discharge.
Covered professional services
For more information see the Medicare Benefit Policy Manual, section 10.2, chapter 6, "Hospital Services Covered Under Part B." Covered services include:
- Physician
- Physician assistant, nurse practitioner and clinical nurse specialist
- Certified nurse midwife
- Qualified psychologist
- Influenza vaccine
- Pnewmococcal vaccine and its administration
- Hepatitis B vaccine and its administration
- Screening mammography
- Screening pap smear and pelvic exam
- Colorectal screening
- Prostate screening
- Bone mass measurements
- Diabetes self-management training
