Normal newborn diagnosis-related group (DRG) claims processing update
Effective July 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will update the claims processing system to ensure accurate payment of newborn claims in accordance with Indiana normal newborn diagnosis-related group (DRG) requirements and the Anthem inpatient authorization requirements for patients enrolled in Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect.
All newborn inpatient stays must have sufficient documentation provided to support admission to an area beyond the newborn nursery, such as a neonatal intensive care unit (NICU), or for the higher level of care associated with the more complex newborn DRG. Documentation to support the higher-level admission includes authorization or medical records.
Failure to provide the appropriate documentation will result in claims processing at the standard newborn rate. Please note that current authorization guidelines for standard newborn and higher level of care baby inpatient stays will be applied.
What is the impact of this change?
- Newborn claims billed with higher level of care newborn DRG codes (tables A and B) must have the required documentation on file. If the required documentation is not on file, the claim will be processed based on the standard well-newborn DRG rate.
- Documentation is required for reimbursement of non-normal newborn care or an inpatient stay beyond the standard well-newborn period or admission to NICU.
- Newborn claims submitted with only newborn care revenue codes (170 and 171) and no authorization for services provided for a higher level of care to support the higher level of care DRG will result in claims paid at the standard rate.
Explanation of Payment code
Based on the information provided above, we have implemented a new explanation (EX) code: A 59 (DRG billed does not match the revenue code submitted). This code will appear on your Explanation of Payment when a claim is billed with a higher level of care newborn DRG code and the required authorization for the higher level of care is not on file. You may appeal your request for payment of the higher acuity DRG by submitting the appropriate supporting clinical documentation. Please follow the normal appeal process detailed in our provider manual, which is available online at www.anthem.com/inmedicaiddoc.
Please click here to view the affected DRG codes.
If you have questions, please call Provider Services:
- Hoosier Healthwise – 1-866-408-6132
- Healthy Indiana Plan – 1-844-533-1995
- Hoosier Care Connect – 1-844-284-1798
May 2020 Anthem Provider News - Indiana