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Prepayment diagnosis-related group (DRG) claim review process

 

As a reminder, we do prepayment claim reviews for specific DRG claims.

 

The goal of the program is to improve the accuracy of our DRG payments. We do this by ensuring that your claim diagnosis and procedure code information is accurate based on the patient’s medical record.

 

More on our review process

  • We use clinical criteria to approve admissions and ongoing inpatient hospital stays. 

  • For DRG facilities, we review the diagnosis codes, procedure codes and other relative clinical information obtained during the Care Management review process.

  • We’ll request records if we find that the DRG billed does not match the diagnosis codes and/or procedure codes in the clinical information available to us at the time of review.

  • When we need records, the hospitals will receive a detailed letter explaining the discrepancy and requesting additional medical records.

  • If we don’t receive records within the stated time frame, we’ll process the claim using the DRG information provided in the letter. 

Helpful tips so you can get paid correctly

To make sure we review your claims quickly and correctly, we’ll need all the right clinical information up front:

  • Work with Aetna Care Management to provide comprehensive clinical information relevant to this inpatient admission.

  • Check to ensure that the ICD diagnosis and procedure codes, as well as the services rendered, support the billed DRG. 

  • If we ask for further medical records, please return them in the timeline referenced. You can send paper copies to the address provided or you can now use our new process and upload medical records electronically via NaviNet. Refer to NaviNet for step-by-step directions.