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Benefit Policy Branch

Diagnosis Related Group

Frequently Asked Questions

There is no foreseeable change in the process.

Yes. Hospitals will receive an electronic file of the relative weights and average length of stay; however, base rates will not be electronic.

Hospitals may only bill for days when the patient was eligible. For proper calculation of the reimbursement, the actual admit and discharge date and all ICD-9 and procedure codes (including those from when the patient was ineligible) should be provided.

The cost-to-charge ratio is the same cost-to-charge ratio used by Medicare for outlier calculations as of Oct. 1 of the preceding year.

Hospitals will still be required to contact the PRO for authorization prior to admission. Concurrent review for services reimbursed under the DRG will no longer be required. Critical access, rehab, ventilator facilities and all psychiatric services still will be subject to concurrent review criteria. The PRO also will be conducting retroactive review of admissions including analysis of coding patterns, changes in case mix, re-admissions, outliers, quality of care, etc. The review will require hospitals to provide copies of medical records upon request and may include onsite review.
Yes, if it is determined that any changes made by Medicare are in the best interests of Medicaid.
The eligibility process will not be affected by the change to DRG reimbursement.
There will be no interim billing with DRGs.
Costs were calculated by multiplying the facility-specified cost-to-charge ratio (described in question 4.) times the covered charges for each claim. Payment will be 80 percent of the amount that the estimated costs exceed the outlier threshold and DRG payment.
Payment, whether DRG or per diem, if paid by DRG it will be based upon the principal diagnosis. Per deim is paid per diem per day.
No. Physicians will need to receive Medicaid provider numbers, and claims must be billed on the CMS 1500.
The rules governing transfers and post-acute care transfers are the same as those used by Medicare.
Yes, if the diagnosis is the same as diagnosis at time of admission.
Yes.
Freestanding rehab will be reimbursed under the per diem system. Rehab provided in an acute care facility will be under DRGs.
There is no change anticipated in the cost report. The paid claims listing is currently being revised and will be shared with the hospitals when completed.

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