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Aetna Changes Stop Loss Calculations

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Beginning September 1, Aetna will change how it calculates reimbursement under stop-loss provisions for participating facilities when inpatient days are denied as “length of stay not necessary."

For per diem contracts when the stop-loss threshold is exceeded and inpatient days are denied, Aetna will use an average cost per day to exclude charges on days that are denied when no itemized bill is available.   If a facility submits an itemization, Aetna will use it to exclude the charges on the denied days.

If an itemized bill is not available to calculate the average cost per day, expenses billed under the following revenue codes will be excluded from the average cost per day calculation:

  • Revenue code 278 – implants
  • Revenue code 360 – operating room
  • Revenue code 370 – anesthesia
  • Revenue codes 710, 719 – recovery room

For DRG contracts, when the outlier/trim days are exceeded, charges on the denied days are excluded.

The change does not apply to Traditional Choice and Aetna Medicare Advantage plans.