Facility Guidelines Overview

Regence follows specific guidelines for billing and payment for facilities. The following guidelines are outlined in this section and apply to all lines of business, except Regence MedAdvantage:

• Billing Inpatient versus Outpatient Stays
  
• Observation
  
• Hospital-based Physician Services
  
• Pre-Admission Services
  
• Room and Board definition
  
• Submission of Maternity/Newborn Claims
  
• Interim Claims
  
• Late Charges
  
• Hospital Corrected billings and/or Adjustments
  
• Grouper use
  
• Ungroupable DRGs
  
• Member Deductible and Coinsurance Calculation
  
• Never Events
  
• Medical Management
  
• Preferred Hemophilia Provider Network Participation Criteria
  
• Oxygen equipment rental only reimbursement

To the extent the terms of this administrative manual are inconsistent with the terms of the participating agreement, the terms of the agreement prevail.

Regence may audit any claim for appropriate coding, payment per contract and payment per Medical and Reimbursement policy. We will request any combination of invoice, medical records or itemized bill to support audit. All documentation requested will be provided within 30 days of the request.

Learn more about:

Appeal process
Review how to appeal a claim denial due to a billing or coding edit dispute

Submitting claims electronically
View information on our various available electronic transactions, including electronic claims submission and electronic claim attachment submission

Claim submission requirements
Find out about our UB-04 requirements

Specific behavioral health details
Locate inpatient or outpatient behavioral health or chemical dependency guidelines

Revised May, 2011