Changes to the Medicaid High Cost Outlier Review Process (201202)

TO: Hospital Chief Executive Officerss
IPRO Liaisons
FROM: Theodore O. Will, FACHE
Chief Executive Officer
DATE: December 6, 2010
RE: Changes to the Medicaid High Cost Outlier Review Process (201202)
IPRO CONTACT:

Kathleen M. Fox, RN, Senior Director – Medicaid/State Healthcare Assessment at extension 361 or Doreen Walz, RN, Assistant Director at extension 444

IPRO, at the direction of the New York State Department of Health (DOH), is amending its high cost outlier review process. These changes are being made as part of the New York State’s Medicaid Program effort to increase provider compliance with the timeliness of submission rules for paid claims requiring correction or resubmission.

Prior to this change in process, hospitals had up to 6-months to re-bill a claim to re-open a high cost outlier review. Effective, as of July 1, 2012, hospitals will have 60 days from the date of notification to re-bill a claim eligible for high cost outlier review.

Under the high cost outlier review program, it is the hospital’s responsibility to re-bill the claim within 60 days of the notification date of the following types of determinations:

1. Initial (1st) Technical Denial Notice, or
2. DRG Change Notice(s), which includes the following:
   1. a preliminary notice where the hospital agrees with the DRG change (AND the hospital submits a DRG WAIVER agreement), or
   2. a final notice of DRG change (where the hospital is not requesting an appeal level review), or
   3. an appeal determination resulting in an upheld or modified DRG change (if the hospital submits a timely appeal request).

NOTE: When either of these two notices is issued, the notification will only be sent to the IPRO Liaison. Thereis no pended high cost outlier claims to alert the hospital’s billing office to re-bill the claim. It is critical that the IPRO Liaison notify the hospital’s Medicaid billing representative when either of these two notices are issued, so that the hospital can re-bill the claim within 60 days from the date of notification of the initial technical denial notice.

Attached, please find an updated overview of the IPRO High Cost Outlier Review Process.

Language in each of the notification letters listed above will clearly state the 60 day re-billing timeframe.

Should you have any questions concerning this memorandum, please feel free to contact Kathleen M. Fox, RN, Senior Director – Medicaid/State Healthcare Assessment, at (516) 326-7767 ext. 361.

Enclosures

• CAIDAdminMemo2012-02-ATTACHMENT-REVIEW-PROCESS.pdf
• NYS-MEDICAID-UPDATE-MAR2012.pdf