Please be aware that effective for dates of service beginning Jan. 1, 2025, Point32Health is making a change to our review process for short inpatient stays and observation services, which is documented in our updated Observation Stay Payment Policy and applies for our Harvard Pilgrim Health Care and Tufts Health Plan Commercial plans and Tufts Health Direct.
Under the updated policy, we will evaluate any request for a short inpatient stay of up to 48 hours to determine if it is more appropriate to categorize the encounter as an observation stay, rather than at an inpatient level of care. Any inpatient notification determined to be consistent with an observation stay as a result of our administrative review will be denied. If a claim is submitted for observation stay, regardless of how it was identified on the initial notification, it will be reimbursed appropriately in accordance with the member’s benefit and the provider’s contract terms.
An observation stay is an alternative to an inpatient admission and allows the facility reasonable and necessary time to evaluate, stabilize, and treat a member whose diagnosis and treatment is not expected to exceed 24 hours, but may extend up to 48 hours before a decision can be made to discharge or admit to inpatient.
The policy is intended to provide greater clarity around what constitutes an observation stay, and it outlines conditions/encounters for which an observation stay designation is and is not considered appropriate — as well as physician and hospital notification and documentation responsibilities, billing guidelines, and more.
Exceptions for which the aforementioned short inpatient stay/observation review will not apply include the following scenarios, which Point32Health would classify as inpatient short stays:
- Admission to a behavioral health facility, including for acute psychiatric or substance use disorder treatment
- Obstetrical admission resulting in delivery
- Admission where the patient was discharged against medical advice or died during hospitalization
- Neonatal admission
- Admission requiring intensive critical care services (such as intubation and mechanical ventilation)
- Patient is transferred to a higher level of care before 48 hours of inpatient admission at the initial facility
Additional exceptions may be evaluated through the provider dispute process. For more information, please refer to the updated Point32Health Observation Stay Payment Policy, as well as our Inpatient Acute and Post-Acute Level of Care (Medical/Surgical) Medical Necessity Guidelines (formerly Inpatient Acute Level of Care [Medical/Surgical]), which we’ve updated to include information regarding post-acute observation stays.