Pre-Payment Review Newborn Inpatient Stays – Marketplace – July 2025

Date: 07/07/25

Payment Policy for Newborn Inpatient Stays

Effective August 15, 2025, Ambetter from Arizona Complete Health is implementing payment policy CC.PP.075 to define payment criteria for newborn inpatient stays to be used in making payment decisions and administering benefits.

Under this policy, assignment of a NICU-level DRG is dependent upon the exclusive billing of NICU revenue codes. When a claim reflects only non-NICU revenue codes (170/171 normal newborn stay), reimbursement will be adjusted to MS-DRG 795 in accordance with health plan policy requirements. When a claim includes both NICU and non-NICU revenue codes billed on the same claim, the claim will be excluded from application of this reimbursement policy.

When a claim is reclassified and reimbursement adjusted to MS-DRG 795, the remittance advice will reflect adjustment code EXHn: Healthy newborn claim paid per policy, submit records for reconsideration. If you disagree with the reimbursement adjustment you may submit a reconsideration request with clinical documentation supporting the diagnosis(es) code billed on the claim that groups to DRG 794 (Neonate with Other Significant Problems).

Reference:

Policy CC.PP.075 Newborn Inpatient Stays is available on our Ambetter website www.ambetterhealth.com > click on AZ in state map > For Providers > Clinical and Payment Policies > Payment Policies

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.