Reconciliation due to All Patient Refined Diagnosis Related Groups (APR-DRGs) Update

Anthem is required to adjust rates in accordance with the All-Patient Refined Diagnosis Related Groups (APR-DRGs) payment methodology, retroactive to the effective date of those rates as determined by the New York State (NYS) Division of Budget. As a result, rates issued by the state in August 2024 will be applied retroactively to all claims submitted with dates of discharge on or after January 1, 2024.

Accordingly, we will perform a reconciliation of the affected claims and will determine the adjusted reimbursement amounts based on the new rates. If, based on our reconciliation efforts, you are due additional reimbursement, we will issue payment at that time. If the adjusted net reimbursement results in an amount due from you to Anthem, we will commence recovery of such amounts through an offset against future claims payments.

Anthem appreciates your continued participation in our network. If you have any questions, contact Provider Services at 800-450-8753.