NEW! Fidelis Care Diagnosis Related Group Change Dispute Form
9/12/2023
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Posted by Provider Relations
A DRG or Diagnosis Related Group is a mechanism used for payment by payers and certain facilities such as short-term acute care hospitals, long-term acute care hospitals, acute inpatient psychiatric hospitals, and acute inpatient rehabilitation facilities.
In a DRG claim type, ICD-10 and ICD-10 PCS codes are submitted by a facility and then grouped into a DRG by computer algorithm. The DRG assigned to the claim is determined by the MS-DRG methodology (created by CMS) if it is a Medicare claim, or by the APR-DRG system (created by 3M company) for non-Medicare claims. As of 2023, New York State is using version 34.0 of the APR-DRG system.
The Fidelis DRG Department monitors DRGs in accordance with the Medicare Program Integrity Manual, Publication #100-08, Chapter 6 - Medicare Contractor Medical Review Guidelines for Specific Services, Section 6.5.3 - DRG Validation Review. This Section specifies that “the goal of DRG validation is to ensure that all reported codes match both the attending physician’s description of the condition, and the information contained in the medical records.”
Upon pre-payment review, DRG claims are either released for payment or a partial payment is made, and medical records are requested. After medical records are reviewed, a DRG determination is made. Facilities may have the opportunity to dispute these findings before the payment is finalized.
To dispute a DRG change made by Fidelis Care please use the DRG Change Dispute Form found here. This form is only applicable if a claim has been processed and a remittance advice has been issued by Fidelis Care.
NOTE: All DRG change disputes must be received within 60 calendar days, or per your contract terms, from the date of the remittance.