Effective immediately, the inpatient hospital claim outlier process will be revised.
Itemized bills must be submitted for all inpatient hospital claim outliers. Historically, if the itemized bill is not submitted with the initial claim it would be denied requesting the additional required documentation. With the move to Diagnosis-Related Group (DRG) pricing we are amending our process to allow payment based on the DRG payment (itemized bills are not required for the base DRG payment) on the EDI submission. Generating payment on the base payment of the DRG on the initial submission for these high dollar claims will help to reduce overall accounts receivable. Hospitals will still be required to submit the itemized bill in order to accommodate outlier payment consideration.
Thanks for all you do!