Date: June 2, 2020
To: Enrolled Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers
Re: Hospital Professional Billing Transition to the Outpatient Institutional Claim Format July 1, 2020
This notice outlines the Department’s plans to shift hospital professional billing to the outpatient institutional claim format and eliminate the use of the Ambulatory Procedures Listing (APL), effective for outpatient claims with a From Date of service on and after July 1, 2020. This applies to claims for participants covered under both traditional Medicaid coverage and Medicaid managed care plans.
1.) Certain services provided in the hospital outpatient and clinic setting are subject to the professional (non-hospital) payment methodology. For these services, hospitals conform to the policies and billing procedures in effect for other non-hospital providers of services.
2.) Otherwise, if an outpatient claim contains at least one procedure code or an emergency department or observation revenue code as listed in the Ambulatory Procedures Listing (APL), all services provided on that day (excluding certain exceptions) must be billed on a single outpatient institutional claim and are paid at the Enhanced Ambulatory Patient Grouping Prospective Payment System (EAPG PPS) outpatient all-inclusive reimbursement.
Effective for outpatient claims with a From Date of service on and after July 1, 2020, the APL is being eliminated, and hospitals must bill all services previously billed as professional services as outpatient institutional services via an 837I electronic transaction, or for claims requiring an attachment, a UB-04 paper claim form.
Beginning July 1, 2020, hospitals must bill all outpatient services under the NPI assigned for institutional services. Hospitals should not use their professional services NPI for dates of service beginning July 1, 2020.
Interim Medicaid Administrator