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[Billing Codes: 4120-01-P; 4830-01-P; 4510-29-P] - page 12 / 83

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coverage that is provided to eligible individuals, as defined in section 2741(b) of the PHS Act.

Authorization and precertification

NMHPA and the interim rules contain three provisions that affect authorization and

precertification for hospital lengths of stay in connection with childbirth.

Under paragraph (a) of the interim rules (relating to hospital length of stay), a group

health plan or a health insurance issuer may not require a physician or other health care

provider to obtain authorization from the plan or issuer to prescribe a hospital length of

stay that is subject to the general rule.

Under paragraph (b) of the interim rules (relating to prohibitions), a plan or issuer may not

restrict benefits for part of a stay subject to the general rule in a way that is less favorable

than a prior portion of the stay. Under an example in the interim rules, a plan or issuer is

precluded from requiring a covered individual to obtain precertification for any portion of

a hospital stay that is subject to the general rule if precertification is not required for any

preceding portion of the stay. However, the interim rules do not prevent a plan or issuer

from requiring precertification for any portion of a stay after 48 hours (or 96 hours), or

from requiring precertification for an entire stay.

In addition, under paragraph (c) of the interim rules (containing rules of construction), a

plan or issuer may not increase an individual’s coinsurance for any later portion of a 48-

hour (or 96-hour) hospital stay. An example illustrates that plans and issuers may vary

cost-sharing in certain circumstances, provided the cost-sharing rate is consistent

throughout the 48-hour (or 96-hour) hospital length of stay.

Compensation of attending provider

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