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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

October 2013

Change in Proration for Inpatient Stays with Partial Eligibility

Effective for dates of service beginning January 1, 2014, Harvard Pilgrim is changing our methodology for prorating diagnosis related group (DRG) or case rate hospital reimbursements when the member is not eligible for the entire length of stay.

Currently, the per diem amount is calculated by dividing the DRG payment or case rate reimbursement by the average length of stay for that DRG. For dates of service after January 1, 2014, Harvard Pilgrim will calculate the per diem amount by dividing the DRG payment or case rate reimbursement by the member’s actual length of stay. This per diem is then multiplied by the number of eligible days for which the member was hospitalized to calculate Harvard Pilgrim’s total reimbursement. We believe this change results in a simplified and equitable reimbursement approach.

For more information, please refer to the Inpatient Acute Medical Admissions Payment Policy.

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Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,

Kristin Edmonston,
Production Coordinator