CHA News Article

Previously Denied DRG Claims Receive ‘Fix’ in Processing System
RAD code 9968 claims now correctly resolved

The Department of Health Care Services (DHCS) has notified providers that previously denied diagnosis related group (DRG) claims that included other health coverage are now being adjudicated appropriately. The claims — remittance advice detail code 9968, “No Approved TAR on File for APR-DRG Inpatient Admission” — have been fixed through edits to the claims processing system. The fix includes a timeliness override to allow claims erroneously denied for 9968 since July 1, 2013, to be processed without a timeliness cutback.

According to DHCS, a DRG claim must be submitted admit-through-discharge on a type of bill 111, even when a beneficiary has coverage other than Medi-Cal fee-for-service for a portion of the stay. All charges, days, diagnosis codes and procedure codes associated with the inpatient episode should be included on the DRG claim submitted to Medi-Cal. Other health coverage must be billed prior to Medi-Cal, and any payments received will be indicated in the prior payments and other health coverage fields of the claim. The final DRG payment will be reduced by payments received by other health coverage.

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