Medicare AdvantageCoverageHigh impact
Two-Midnight Rule: New FAQ Document Offers Greater Clarity for MA Organizations
Highmark·PA, DE, NY, WV·Provider Bulletin
Effective date
Jan 1, 2024
We identified it
Jun 26, 2026
Summary
Highmark has released a new FAQ document clarifying the Two-Midnight Rule (TMR) for Medicare Advantage Organizations (MAOs). Effective 2024, the TMR now applies to MAOs, but critically, MAOs retain the right to perform clinical review of inpatient hospital stays for medical necessity even when the Two-Midnight Presumption is met—unlike Traditional Medicare where the presumption generally insulates claims from review. Billing teams must understand that Highmark MA plans may deny inpatient admissions that cross two midnights if medical necessity cannot be demonstrated, regardless of the Two-Midnight threshold.
Action Required
Immediately: Billing and prior authorization teams must review the new Two-Midnight Rule FAQ document (available on Highmark's Provider Resource Center Electronic Claims page) and update internal policies to reflect that Highmark MA plans are NOT bound by the Traditional Medicare Two-Midnight Presumption. Providers must: (1) Ensure all inpatient hospital admissions under Highmark MA plans include comprehensive medical necessity documentation in the medical record, even for stays crossing two midnights; (2) Obtain or verify prior authorization for inpatient admissions rather than relying on the Two-Midnight Presumption; (3) Train clinical and billing staff that Highmark may conduct clinical review of any inpatient stay and deny claims lacking documented medical necessity. Update admission protocols and EMR templates to prompt providers to document complex medical factors justifying inpatient care. Failure to comply may result in claim denials for inpatient hospital services.