Empire to accept Hospital in Home services
Effective July 1, 2022, Empire recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Empire contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims.
The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Empire for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.
The following Empire benefit plans are in scope for participation in HiH:
- Empire Commercial
- Medicare Advantage (Individual and Group)
- Medicare Advantage Special Needs plans, including Dual-Eligible Special Needs (D-SNP)
The following Empire plans are out of scope for participation in HiH:
Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Empire suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
Facility shall not bill Empire or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
Notify Empire immediately through the utilization management nurse assigned to the HiH case when:
- An applicable member is admitted to the HiH program
- A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Empire Agreement and/or as outlined in the applicable Empire provider manual.
We will continue to update billing guidance as these programs evolve.
September 2022 Newsletter