Per Diem agreement and allowed amount calculation

Per Diem

Per Diem is a per day negotiated rate which represents an allowance that includes all services for that day.

Per Diem agreements reimburse based on the admission date of the member.

The following terminology is used when referring to per diem contracts:

• Inliers- Inpatient cases reimbursed based on room and board per diem rates

• Outliers- Inpatient cases reimbursed as a DRG carve-out or based on catastrophic reimbursement.

Per Diem Hierarchy for a Standard Base Agreement

Each inpatient case in a per diem contract is evaluated using the following payment hierarchy:

• Implant Carve-out - Typically reimbursed in addition to inliers and outliers

• Catastrophic - Outlier

• DRG Carve-outs as case rate with additional day per diem - Outlier

• Per Diem Rates - Inlier

Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step.

Calculating the Inpatient Allowed Amount

Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied. Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.

Per Diem Examples

Per Diem payment rate is based on room and board revenue codes (e.g., med/surg, ICU, psychiatric) ranging from 110-219. The following examples illustrate the per diem methods for determining payment for inpatient admissions. Per Diem Examples

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