Hospitals should not bill for an inpatient acute level of care status when an EmblemHealth Medicaid member has been transferred to an Alternate Level of Care (ALC) status.
New York Codes, Rules, and Regulations (NYCRR), Title 10, § 86-1.15(h), defines ALC services as:
Those services provided by a hospital to a patient for whom it has been determined that inpatient hospital services are not medically necessary, but that post-hospital extended care services are medically necessary, consistent with utilization review standards, and are being provided by the hospital and are not otherwise available.
Hospitals should not bill for acute levels of care for days when members are in an ALC setting. Hospitals must properly report occurrence span code “75”, with the occurrence span date(s) the member was in ALC, on the acute care claim. eMedNY Inpatient Billing Guideline § 2.3.3 requires that ALC claims be split-billed. Split-billing is defined in the guideline as the:
Submission of multiple date range claims that when compiled represent the period from Admit to Discharge.
For additional information regarding inpatient billing, providers may refer to the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital Manual.
To request authorization for ALC, providers should submit requests by fax at 866-544-9387 or email to MA_DISCHAPLAN@emblemhealth.com with a clear indication requesting transition to ALC.
JP #56547 10/2022
