Pre-Payment Inpatient High Dollar Claims Review Update II
Date: 06/27/25
Pre-Payment Clean Claim Review of Inpatient High Dollar Marketplace Claims
Effective August 1, 2025, Ambetter from Arizona Complete Health is partnering with 6 Degrees Health to initiate pre-payment clean claim review of high dollar Marketplace inpatient claims. The review will be based on the CMS Provider Reimbursement Manual sections 2202.6 and 2203 and are delineated in our payment policies, CC.PI.04, CC.PI.06 and CC.PI.10. Links to these references are included below.
Inpatient hospital claims payment under DRG pricing is comprised of a DRG base payment and a DRG outlier add-on payment. Not all claims qualify for a DRG outlier add-on payment. Inpatient high dollar claims review seeks to identify charges that are separately reimbursable and charges that are not separately reimbursable for purposes of outlier add-on payment.
To determine appropriate outlier add-on payment for qualifying claims, a detailed review of the comprehensive itemized bill and related documentation in accordance with State and CMS guidelines, and Health Plan payment policies is completed prior to processing an outlier add-on payment.
Reminder:
For Medicaid claims, review incorporates the Arizona DRG Payment Policies, including but not limited to the AHCCCS Fee-For-Service Provider Billing Manual Exhibit 11-2 Nursing Service Outliers. Additionally, Health Plan payment policies, including but not limited to CC.PI.04, CC.PI.06, and CC.PI.10, are utilized in the review. These policies refer to the CMS Provider Reimbursement Manual sections 2202.6 and 2203. Links to these references are included below.
For Medicare claims, the review is based on the CMS Provider Reimbursement Manual sections 2202.6 and 2203 and are delineated in our payment policies, CC.PI.04, CC.PI.06 and CC.PI.10. Links to these references are included below.
References:
1. CMS Provider Reimbursement Manual sections 2202.6 and 2203
https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals-items/cms021929
(See Chapter 22)
2. Policies Clean Claim Review CC.PI.04, Cost to Charge Adjustments on Clean Claims CC.PI.06 and Unbundling Adjustments on Clean Claim Reviews CC.PI.10 are available on our website www.azcompletehealth.com > For Providers > Provider Resources > Clinical & Payment Policies > Payment Policies and on the marketplace website www.ambetterhealth.com > click on AZ in state map > For Providers > Clinical and Payment Policies > Payment Policies
3. Arizona DRG Payment Policies Document
https://www.azahcccs.gov/PlansProviders/RatesAndBilling/ManagedCare/DRGbasedpayments.html
4. AHCCCS Fee-For-Service Provider Billing Manual Exhibit 11-2 Nursing Service Outliers
https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/Exhibit11-2Outliers.pdf
Summary of key steps in the inpatient high dollar claims review process:
1. Inpatient hospital claims reimbursed under DRG pricing are paid the DRG base payment, as appropriate
2. High dollar inpatient claims are identified for review to determine outlier add-on payment
3. For identified claims, your Medical Records Department receives a request to provide a comprehensive itemized bill and related documentation
4. Upon receipt and review of documentation, a detailed report of finding(s) are shared with you
5. Separately reimbursable charges are priced per the outlier payment methodology and the outlier add-on payment is processed as appropriate
6. If you do not agree with the findings, you may submit a reconsideration or a claim dispute/appeal with additional documentation justifying additional payment. If a charge initially found to be ineligible for reimbursement is determined payable following review, the claim is reprocessed accordingly.
If you have questions, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us: AzCHProviderEngagement@azcompletehealth.com.