Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
This is an update to the article titled “TMHP to Revert Back to Grouper Version 36 of the APR-DRG System to Process Inpatient Claims” that was published on this website on November 24, 2020.
Most inpatient claims with discharge dates on or after September 1, 2020, which were originally processed under the All Patient Refined-Diagnosis Related Groups (APR-DRG) Grouper version 37.1, have been reprocessed using Grouper version 36 logic and relative weights. However, some claims did not regroup as expected. In addition, other claims, which were submitted during the impacted period but not captured in the reprocessing, have been identified. These claims that did not regroup or were not captured in the initial reprocessing are currently being reprocessed.
Also, the Texas Health and Human Services Commission (HHSC) reviewed claims with discharge dates between October 1, 2019, and August 31, 2020, that were processed under APR-DRG Grouper version 37 and 37.1. The impacted claims have been identified and are currently being reprocessed using Grouper version 36 logic and relative weights.
Note: HHSC is currently reviewing processes to analyze the fiscal impact of annual APR-DRG version logic changes. Relative weights will be recalibrated, if necessary, before each version implementation. TMHP will publish updated information as it becomes available.
Impacted inpatient hospital claims that were originally reimbursed at a lower than expected reimbursement rate will be reprocessed and providers may receive additional payments. Also, any payments made in excess may be deducted from future payments (i.e., recouped). Payments and deductions will be reflected on future Remittance and Status (R&S) Reports.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.