QUEST Integration – Room Differential

Effective admission dates starting from July 1, 2022, this policy applies to HMSA QUEST Integration members. QUEST Integration members will not be liable for any additional out of pocket costs. Providers are liable for the difference.

The following are the QUEST Integration reimbursement guidelines for Room and Board Differential:

1. Private Room
   1. HMSA covers private rooms when medically appropriate for the member’s condition. Refer to the Private Rooms page to access the list of ICD-10 CM diagnosis codes and ICD-10 CM procedure codes for which a private room is considered medically appropriate.
   2. The payment from HMSA will be considered payment in full. Provider will be liable for the difference.
2. Room Differential
   1. Providers shall use best efforts to provide HMSA forty-five (45) calendar days advance notification for any changes to room and board charge master. Notice shall be in writing and include a schedule of adjusted charges for room and board. HMSA reserves the right to implement updates to charges forty-five (45) calendar days from date of receipt. Please note only certain room and board charges are recognized by HMSA.
   2. The provider will be liable for the difference between the billed charges and the allowable charge.
3. Lower Level of Care
   1. When members drop to SNF or ICF waitlisted level of care, we recognize the appropriate charge for that level of care. 
   2. The provider will be liable for the difference between billed charges and the appropriate charge based on level of care.

Refer to the link below to access the QUEST Integration APR DRG page: MQD QUEST Integration – All Patients Refined Diagnosis Related Groups

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