CHA News Article

DHCS Will Reprocess Certain DRG Claims

The Department of Health Care Services (DHCS) has resolved a claims processing issue that caused diagnosis-related group (DRG) claims that included other health coverage to be erroneously denied. Timeliness will be waived for claims that were previously denied with remittance advice details (RAD) code 9968 (“no approved TAR on file for APR-DRG inpatient admission working”) for dates of service from July 1, 2013, through March 1, 2015. Hospital providers may resubmit claims until November 20.

DHCS also notes that other health coverage must be billed prior to Medi-Cal being billed, and any payments received will be indicated in the Payer Name (Box 50) and Prior Payments (Box 54) sections of the UB-04 claim form. The final DRG payment will be reduced by payments received by other health coverage.

Claims resubmitted must contain the following on the UB-04 claim form to receive reimbursement:

  • In the Remarks field (Box 80), add the statement: “DRG claim that previously denied with RAD code 9968;” and
  • Indicate delay reason code “11” in the appropriate field.

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