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.