Changes to Beyond Medical Necessity Reimbursement for YouthCare Members

Date: 10/30/24

Per updated Illinois compiled statute, 305 ILCS 5/14-13f, effective January 1, 2025, reimbursement for Beyond Medical Necessity (BMN) days for YouthCare begins on the third day a child is in the hospital beyond medical necessity. While there is no payment for days one and two, they must be billed on the claim to ensure appropriate reimbursement for all remaining days. Please note, this update is applicable only to YouthCare, and not Meridian Medicaid Plan.

To align with this legislative change, payments will be as noted for BMN claims that start after January 1, 2025:

Behavioral Facility	Day 1-2 – no reimbursement
Behavioral Facility	Days 3-32 – $400 per diem
Behavioral Facility	Day 33+ – $600 per diem
Acute Care Facility	Day 1-2 – no reimbursement
Acute Care Facility	Day 3+ – $289.48 per diem

 

Additionally, the following billing guidance should be followed:

• Comprehensive review of billing administrative days is available in the IAMHP Billing Manual Appendix I located on the Illinois Association of Medicaid Health Plans (iamhp.org) website
  
  
• Claims for medically necessary admission require prior authorization and should be billed per billing guidelines for DOS of the medical stay, including interim billing when applicable
  
  
• Final Medical Inpatient claims should be billed with a discharge status of 95 - Discharged/transferred to another type of health care institution not defined elsewhere in this code
  
  
• BMN claims should be billed starting with the day after discharge for the medical stay with the appropriate TOB – 111/112, as this is considered a new stay
  
  
• All BMN claims should be billed with a Revenue Code 0169 – Room and Board Other. Any additional services billed on the claim will not be reimbursed
  
  
• Standard interim billing rules should apply for BMN days that extend beyond 30 days
  
  
• Value codes must be billed in accordance with the guidance the IAMHP billing Appendix I
  
  
• If the member returns to a medical admission, the BMN should be billed with a discharge status of 65 if admission is Psych, or 02 if admission is medical
  
  
• Each move between medical admission and BMN should be billed as a unique admission for coding of the claim. However, payment will be continued at the accumulated days for behavioral health facilities and day 33+ will pay at $600 per diem
  
  
• The primary medical health (PH) or behavioral health (BH) diagnosis utilized for the prior inpatient claim should be submitted in the first diagnosis position to ensure the appropriate reimbursement. If a diagnosis is considered shared by medical or BH, for example – depression, the claims will be reimbursed at the BH rate
  
  
• YouthCare requests that Z62.21 – Child in welfare custody be utilized in the second diagnosis field
  
  
• Claims are subject to the 180 days timely filing limit
  
  
• While BMN days do not require authorization, if a YouthCare member returns to a medical admission status while waiting for placement, facilities must request prior authorization for those days in accordance to established procedures
  
  
• When YouthCare members move between medical admission and BMN while waiting for placement, a specific claim is needed for the status of the member which includes the days in each status
  
  
• Clinical reviews will occur every seven days for all BMN youth
  
  
• Clinical documentation should be submitted to Utilization Management via
  
  • fax: 1-833-387-3173 or,
  • phone: 844-989-0154

 

Please refer to the IAMHP Billing Manual Appendix I for examples of how a claim should be billed.

Thank you for your collaboration and for helping our members live better, healthier lives. For more information or for questions or concerns, please call YouthCare at 844-289-2264, Monday through Friday from 8 a.m. to 6 p.m.