DRG Grouper Billing Guidelines; Change to Utilization Management’s Medicaid 800 Line and Change to Utilization Management’s Process for Voicemail Messages

DRG Grouper Billing Guidelines

Gateway Health Plan^® requires claims to be billed with the correct DRG code based on the grouper which is in effect for the DOS and Line of Business for which you are submitting a claim.

PA Medicaid – We have not received any indication from DPW that they have updated groupers. Medicaid is currently pricing off of Grouper 23. All claims should continue to be billed with the appropriate DRG code from Grouper 23. We do not crosswalk DRG codes. If you bill with a DRG code from any other Grouper, the claim will deny as “Invalid DRG” and you would have to re-submit the claim with the appropriate DRG from Grouper 23 in order to receive payment. All corrections would be held to the timely filing limitation of 120 days from the date of the original remit.

Medicare Assured^® HMO – We are currently using MS-DRG 25. We will update to Grouper 26 when Medicare makes their update to Grouper 26.

PLEASE NOTE: The information above applies to the submission of DRG codes only. As required by HIPAA, diagnosis Codes are updated annually for both Lines of Business and claims must be submitted with the most current, valid, DX codes for BOTH lines of business.

Change To Utilization Management Medicaid 800 Line

In order to better service our providers, the UM department has made menu changes to the Medicaid 800 line effective October 1, 2008. These changes include options to reach someone in Pharmacy, Provider services and Medicare Assured^® HMO.

Change To Utilization Management Process For Voicemail Messages

Based on feedback received from the provider community, beginning 10/1/2008 nurses in the UM department will be able to accept clinical information via voicemail. If you are calling a nurse in the department with an inpatient review or information related to a specific request, you may leave the clinical information on the voice mail of the nurse you are working with to obtain approval. The nurse will call you back if additional information is needed and you will be notified of the outcome of your request. This change applies to both Medicaid and Medicare Assured^® HMO products.