As a reminder, Point32Health updated our review process for short inpatient stays and observation services, effective for dates of service beginning Jan. 1, 2025 for our Harvard Pilgrim Health Care and Tufts Health Plan Commercial plans and Tufts Health Direct. We also want to make you aware of the expedited review process in the event that you believe an inpatient request has been incorrectly denied.

About the policy

As noted in our Observation Stay Payment Policy, we will evaluate any request for a short inpatient stay of up to 48 hours to determine if it is more appropriate to categorize the encounter as an observation stay rather than an inpatient stay for payment purposes. An observation stay is an alternative to an inpatient admission and allows the facility reasonable and necessary time to evaluate, stabilize, and treat a member whose diagnosis and treatment is not expected to exceed 24 hours, but may extend up to 48 hours before a decision can be made to discharge or admit to inpatient.

Any inpatient notification determined to be consistent with the parameters outlined in the payment policy will be administratively denied. If a claim is submitted for observation stay, regardless of how it was identified on the initial notification, it will be reimbursed appropriately in accordance with the member’s benefit and the provider’s contract terms.

The policy is intended to provide greater clarity around what is reimbursable at an observation rate, and it outlines physician and hospital notification and documentation responsibilities, billing guidelines, and more.

Exceptions to the short stay policy include the following scenarios, which Point32Health will review as standard inpatient requests:

  • Admission to a behavioral health facility, including for acute psychiatric or substance use disorder treatment
  • Obstetrical admission resulting in delivery
  • Admission where the patient was discharged against medical advice or died during hospitalization
  • Neonatal admission
  • Admission requiring intensive critical care services (such as intubation and mechanical ventilation)
  • Patient is transferred to a higher level of care before 48 hours of inpatient admission at the initial facility

Additional exceptions may be evaluated through the provider dispute process. 

About the provider dispute process

In the event you believe we have incorrectly denied an inpatient request under our short stay policy, you may request a review to determine if the encounter meets our policy exceptions criteria. 

Submit your request by email to [email protected] along with the following information:

  • Member ID
  • Date of service
  • Specific reason for exception from short stay policy
  • Claim ID (if applicable)

Please do not include clinical records in your email, and if you are sending a request for multiple members send separate emails for each individual. 

Point32Health will acknowledge receipt of your request within two business days, and will provide a decision or further instructions within six business days. 

Physicians are involved in review of expedited requests to determine whether the circumstances may warrant an exception to the payment policy. 

In the event an exception is granted, the admission will be reviewed using InterQual criteria to evaluate medical necessity. 

For more information, please refer to the Point32Health Observation Stay Payment Policy and our Inpatient Acute and Post-Acute Level of Care (Medical/Surgical) Medical Necessity Guidelines, as well as the inpatient sections of the Provider Manuals.