FLASH: CMS Guidelines and Inpatient Admissions

The 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) from the Centers for Medicare & Medicaid Services (CMS), effective January 1, 2024, outlined important information around Medicare Advantage enrollee admission for inpatient care.

The two-midnight rule has been a long-standing CMS Part A regulation that defines when inpatient admissions are appropriate for payment. We will continue to review our Medicare Advantage member inpatient admissions by applying appropriate Medicare coverage guidelines where available, InterQual^® criteria, American Society of Addiction Medicine (ASAM) criteria or our internal coverage criteria to make determinations for medically necessary care.

This 2024 Final Rule requires that all Part C Medicare Advantage plans follow the two-midnight rule regulation providing coverage for an inpatient admission with the following conditions:

• Based on consideration of complex medical factors documented in the medical record, the admitting physician expects the patient to require hospital care that crosses two midnights (two-midnight benchmark).
• When the admitting physician does not expect the care to cross two midnights but determines, based on complex medical factors documented in the medical record, that inpatient care is still necessary (case-by-case exception).
• The inpatient admission is for a surgical procedure specified as inpatient only under Medicare (the Medicare Inpatient-Only list).

Providers and facilities should document and evaluate in the EMR the following:

• The patient’s medical factors and the expectation that two or more midnights of medically necessary inpatient care is reasonable and is supported by information in the medical record.
• When the expectation is that the care will not cross two midnights, a case-by-case exception is documented.
• In each case, we require the medical documentation that supports medical necessity of an inpatient admission to be submitted to us by fax or, if we access your EMR, it is clearly referenced in your notes.

We will review the provider’s or facility’s clinical documentation and supporting information in the medical record which demonstrates medically necessary care. If coverage criteria are not met at one of the acute inpatient levels of care, our medical director will review the request to determine medical necessity by applying the appropriate coverage criteria.

Note: We do not require notification or perform concurrent review for observation level of care, for Medicare Advantage members.

We know these changes might present challenges for hospitals and providers who document inpatient care. We’ve provided some resources below that can help support your admissions for inpatient level of care.

• Notify us of your patient’s admission within 24 hours and include the relevant clinical information at the time of your notification.
• Include both phone and fax number where your utilization review team can be reached.
• If the patient’s level of care changes after you’ve notified us, please contact us.
• Include the following clinical information with your admission notification:
  • In your admission order, clearly state the inpatient level of care, as appropriate.
  • Document your consideration of complex medical factors necessitating your expectation that the patient requires hospital care crossing two midnights for inpatient level of care.
  • Document when you do not expect the care to cross two midnights but have determined inpatient care is still necessary (case-by-case exception).

We will review your documentation supporting the factors above to determine medical necessity outside of the appropriate coverage criteria.

Use this Provider Checklist for Review of Inpatient/Mental Health/Substance Use as a guide to help ensure that all necessary information is submitted to us. You can also find this checklist and other provider resources here: Provider Resources.

We have included this CMS fact sheet as a brief reference for additional information. As always, feel free to reach out to your Provider Relations Specialist or contact our Customer Solutions team at (800) 851-3379 if you have questions.