Pre-Payment Inpatient High Dollar Claims Review Reminder

Date: 04/25/25

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.

As a reminder, to determine appropriate outlier add-on payment for qualifying claims, Arizona Complete Health conducts a detailed review of the comprehensive itemized bill and related documentation in accordance with AHCCCS and CMS guidelines, and Health Plan payment policies prior to processing an outlier add-on payment.

For Medicaid claims, review incorporates the AHCCCS APR-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, review incorporates the CMS Provider Reimbursement Manual sections 2202.6 and 2203 and are delineated in Health Plan payment policies, including but not limited to CC.PI.04, CC.PI.06, and CC.PI.10. Links to these references are included below.

References:
1. Arizona DRG Payment Policies 
2. AHCCCS Fee-For-Service Provider Billing Manual Exhibit 11-2 Nursing Service Outliers 
3. CMS Provider Reimbursement Manual sections 2202.6 and 2203
 (See Chapter 22)
4. Policies CC.PI.04, CC.PI.06 and CC.PI.10 are located on our website www.azcompletehealth.com > For Providers > Provider Resources > Clinical & Payment Policies > Payment Policies

Below is a summary of key steps in our inpatient high dollar claims review process
1. Inpatient hospital claims that are 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 have the right to 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.