General
Chapter 1
Section 31
Newborn
Charges
Issue Date: July 19, 1983
Revision:
1.0 ISSUE
How are charges for newborn
care to be billed?
2.0 POLICY
2.1 Under
the Diagnosis Related Group (DRG) based payment system, there are
separate DRGs for the mother and the newborn. Therefore, separate
claims must be submitted for the mother and the newborn, whether
or not the newborn care is considered routine. Since the vast majority
of deliveries will be subject to the DRG-based payment system, and
to maintain consistency in processing, all newborn services must
be billed separately from the mother’s claim, except as provided
under
paragraph 3.0.
2.2 In the
case of multiple births, separate claims must be submitted for each
newborn.
2.3 Claims for newborn care for
maternity episodes of active duty members, is covered if a separate claim
is submitted to the contractor for the newborn.
2.4 Separate professional claims
must be submitted for the mother and the newborn.
3.0
POLICY
CONSIDERATIONS
3.1 There are some cases where
the newborn stays in the mother’s room and does not incur nursery
charges. It would not be appropriate to pay such cases under DRG
391, Normal Newborn, because the basic service of that DRG is nursery
charges. Therefore, the newborn services in such cases shall be
exempt from the DRG system and paid based on billed charges. In
order to pay such services based on billed charges, the following
conditions must be met.
3.1.1 The services,
if they were paid under the DRG-based payment system, would group
only into DRG 391.
3.1.2 There
can be no nursery/room charges for the newborn.
3.1.3 The billed charges for the
newborn (pharmacy, supplies, etc.) must be included on the mother’s
claim.
3.2 In processing
such claims, the contractor will split the mother’s claim to separate
any charges for the newborn. The mother’s claim will be paid under
the appropriate DRG. If double coverage is involved, the Other Health
Insurance (OHI) payments shall be applied first to the mother’s
claim and then to the newborn claim if any OHI payment remains uncoordinated
after application to the mother’s claim.
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