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.