Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
This review of hospital-requested
claim adjustments assures that the correct diagnosis and procedure information
is provided on the adjusted claim form. Thus, the correct Diagnosis
Related Group (DRG) can be determined and the adjustment difference
can be paid by the contractor.
A hospital may file an adjusted claim. A change
in the principal diagnosis or the sequencing of the diagnoses or
procedures may result in a change to a DRG with a higher weight
providing for a higher reimbursement rate. Such cases should be
closely reviewed before the hospital sends the cases to the contractor
for adjusted payment.
When a hospital wishes to submit an adjusted
claim, the hospital must send the case directly to the contractor
to be reviewed within 60 days of the date of the initial remittance
advice. The hospital must provide all of the following information
within the 60-day time frame:
• A copy
of the initial remittance advice;
• A copy of both the original and updated attestation; OR
• A copy of the original attestation which has
been corrected and corrections initialed and dated by the attending
physician;
• The codes
submitted for adjustment;
• An explanation of why the original codes were
submitted incorrectly;
• A copy of the original claim form (CMS 1450
UB-04);
• A copy
of the adjusted claim form;
• A copy of the medical record as required for
performing admission review and DRG validation;
• If coding changes are based on newly acquired
clinical information, a copy of such information (e.g., autopsy
report).
The contractor shall check the date on the
remittance advice to determine if the request for adjustment is
made within 60 calendar days from the date of the remittance advice.
If the 60 day period has expired, the contractor shall deny the
claim adjustment and return it to the hospital with a letter explaining
the reason for the denial.
Note: If all required documents are not provided, the
case shall be returned to the hospital as incomplete. If the required
documents are returned to the contractor within the 60-day time
frame, the case shall be reviewed. If returned after the 60-day
time frame, the case will not be reviewed.
If the hospital submits a request for a higher
weight DRG on a case that has previously been scheduled for retrospective
review, the case shall be returned to the hospital without review.
DRG validation is performed during routine review procedures.
If the 60-day period has not expired and all
of the required information has been submitted, the contractor shall
use the adjusted codes to regroup the case to determine if it regroups
to a higher weight DRG. Only adjusted claims that result in a higher
weight DRG will be reviewed. If the case does not regroup to a higher
weight DRG, the case shall be returned to the hospital without review.
If the case does regroup to a higher weight DRG, all required reviews
shall be performed. When potential denial or a coding change other
than that requested occurs, appropriate notice letters shall be
issued.
The adjusted claim shall be stamped as “APPROVED”
or “DENIED” for DRG validation and returned to the hospital along
with a letter stating the review results. The hospital then submits
an “APPROVED” adjusted claim to the contractor and the “APPROVED”
decision stamp flags the claim for adjusted payment. Adjusted claims
cases resulting in higher weight DRGs are not eligible for re-review.
The Request for Higher Weight DRG Review form
has been developed for use by hospitals in requesting review of
higher weight DRG claim adjustments. This form must be completed
and submitted with all requests. This form has been developed to
assist hospitals in assuring that all required documents are sent
with the request for review. Such requests may only be submitted
by hospitals. Vendors or consultants may not request
higher weight DRG reviews. Any record submitted by
these individuals will be returned to the hospital. ALL REQUESTS
FOR HIGHER WEIGHT DRG REVIEW MUST BE RECEIVED WITHIN 60 DAYS FROM
THE DATE OF THE INITIAL REMITTANCE ADVICE.