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Pre-Admission Testing

Reimbursement Policy:
Pre-Admission Testing

Effective Date:
January 1, 2003

Last Revised Date:
August 4, 2020

Purpose:
This policy outlines our guidelines for the reimbursement of pre-admission testing (PAT) services.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

  • Pre-Admission Testing: Includes any service related to a patient’s planned inpatient admission or same day surgery that is performed on the day of, or within the 72-hour period prior to the day of, a patient’s planned inpatient admission or same day surgery service.

Pre-Admission Testing services are considered related to an inpatient admission or same day surgery if the outpatient principal diagnosis is similar to, or the same as, the inpatient or same day surgery diagnosis.

Policy:
Horizon BCBSNJ considers all medically necessary outpatient services related to a member’s planned inpatient admission or same day surgery that are provided to that member by the admitting hospital or associated or affiliated entity (e.g. part of hospital system, affiliated ambulatory surgery center), on the day of, or in the 72-hour period prior to the day of that member’s planned admission or same day surgery to be pre-admission testing.

This includes, but not limited to, COVID-19 testing for all planned inpatient admissions and same day surgery services.

Procedure:
PAT services performed on the day of, or in the 72-hour period prior to the day of, that member’s planned inpatient admission or same day surgery service are NOT considered for separate reimbursement.

Outpatient services that are not related to a member’s planned admission or same day surgery performed on the day of or in the 72-hour period prior to the day of a patient’s planned inpatient admission may be considered for separate reimbursement.

Ambulance services provided on the day of, or in the 72-hour period prior to the day of, a patient’s planned inpatient admission or same day surgery service are not considered pre-admission testing.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

CPT is a registered trademark of the American Medical Association

History:

04/15/2011: Policy approved

02/06/2012: Update to SDS criteria to allow separate reimbursement for same claim/same DOS PAT services.

07/09/2014: Revised and reformatted content for clarity per Legal.

07/30/2015: Removed “by an entity owned or operated by the hospital…” from Policy: section. Revised Procedure: section, Paragraph 2 “admissions may be…”

08/04/2020: Added reference to COVID-19 testing and “associated or affiliated entity” language within the Policy: section.

Policy 058_v5.0_08042020