Clinical review of inpatient bed days Sample Clauses

Clinical review of inpatient bed days. If a determination is made after a Customer becomes an inpatient that certain services are not medically necessary (including cases in which a part of an admission is determined to be medically necessary and part of the same admission is determined not to be medically necessary), the claim with regard to services that are not medically necessary (including room, board, and other services for a given day) may be denied and Participating Facility must not seek or collect payment from the Customer. Payment will be made in accordance with the applicable payment appendix for the part of the admission that is determined to be medically necessary, and Participating Facility may collect from the Customer the applicable copayment, deductible or coinsurance for that part of the admission. A claim may also be denied in whole or in part under this subsection 1.9(iv) in cases in which services cannot be determined to be medically necessary due to omission of information or failure to respond to United’s request for information; Participating Facility may request reconsideration of such a denial on grounds of medical necessity. United will not reduce payment under this subsection 1.9(iv) when the contract rate for the claim is not impacted by the length of stay, because the contract rate is determined by an MS- DRG or similar methodology and is not subject to an inpatient outlier provision.
Sample 1
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