(a) Payment is made for the use of a treatment room associated with outpatient observation services.Observation services must be ordered by a physician or other individual authorized by state law. Observation services are furnished by the hospital on the hospital's premises and include use of the bed and periodic monitoring by hospital staff. Observation services must include a minimum of eight (8) hours of continuous care. Outpatient observation services are not covered when they are provided:
(1) On the same day as an emergency department visit.
(2) Prior to an inpatient admission, as those observation services are considered part of the inpatient DRG.
(3) For the convenience of the member, member's family or provider.
(4) When specific diagnoses are not present on the claim.
(5) As part of another service, i.e. for post operative monitoring; recovery after diagnostic testing or concurrently with therapeutic services such as chemotherapy.
(b)Payment is made for observation services in a labor or delivery room. Observation services must include a minimum of eight (8) hours of continuous care. Specific pregnancy-related diagnoses are required.