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.