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Frequently Asked Questions

Diagnosis Related Group (DRG) claims - what are the billing procedures for DRG claims and DRG with Alternate Level of Care?

Rate Codes:

DRG claims for NYS Medicaid are Rate-based. The Rate Code is sent in the 837 Institutional Claim in loop 2300, in the Value Information segment.
DRG claims are identified by the following Rate Codes:

In-state Inlier : 2946
In-state Outlier : 2956
Out-of-state Inlier : 2953
Out-of-state Outlier : 2958

General Billing Principles:

All DRG claims can be billed from Admission to Discharge and do not have to be split billed according to the high trim point, which is the date that separates Inlier and Outlier segments.

Claims can be billed for the period from admission to discharge under rate code 2946 even if the “high trim point” was within the DRG period (in other words the DRG inpatient stay included both Inlier and Outlier segments). The eMedNY system will automatically assign the Outlier rate code for the days after the high trim point.
DRG claim have to be billed, at a minimum, up to the high trim point for the DRG assigned.
The high trim point day itself is part of the Inlier period.
The payment amounts for the Inlier and Outlier segments will be added together and paid as one sum. This amount will be reported on the remittance advice under Rate Code 2946.

All DRG claims must have the actual hospital discharge date regardless of the Patient Status Code in the claim.

The discharge date will not match the end date of service if the patient status is 30, Still a patient.

For DRG claims, the NYS Medicaid 90-day timely submission requirement is applied based on the discharge date reported on the claim.

Reporting Covered and Non-Covered Days:

The days that are reported in the 837 Institutional claim as covered or non-covered by Medicaid and any prior Coordination of Benefits (COB) payers such as Medicare are expected at the following locations:

Days Type	Loop	Segment	Element
Medicaid Covered Days	2300	QTY segment with Qualifier CA (QTY*CA)	QTY02
Medicaid Non-Covered Days	2300	QTY segment with Qualifier NA (QTY*NA)	QTY02
Medicare Coinsurance Days	2300	QTY segment with Qualifier CD (QTY*CD)	QTY02
Medicare Lifetime Reserve Days	2320 2300	MIA segment QTY segment with Qualifier LA (QTY*LA)	MIA02 QTY02
Medicare Covered Days	2320	MIA segment	MIA01
Other Insurance Covered Days	2320	MIA segment	MIA01

Alternate Level of Care within the DRG period:

There are certain billing procedures that must be followed when specific scenarios occur. One common billing scenario involves a DRG Acute Care inpatient stay that includes one or more episodes of Alternate Level of Care (ALC).

ALC services are not billable on DRG claims. If an ALC period is involved, then a separate, additional claim must be billed.
ALC is indicated with Occurrence Span Code 75, “SNF Level of Care”. The patient is still in the hospital but has been moved from Acute Care to a reduced level of care. The Occurrence Span Code is sent in the 837 Institutional Claim in loop 2300 in the Occurrence Span Information segment.
All claims for ALC must contain Occurrence Span Code 75 with the date range the patient was on ALC.
The admission date on the ALC claim will be the date of admission to Acute Care – not the date of admission to the Alternate Level of Care.

ALC (non-DRG) claims can be billed as interim claims. If a non-DRG claim is billed as an interim bill the patient status code is 30, “Still a patient” and no discharge date is entered. The discharge date is only reported on an ALC claim if the Patient Status Code in the claim indicates a discharged patient. The Patient Status Code is sent in the 837 Institutional claim in loop 2300, in the Institutional Claim Code segment.

For non-DRG claims the Medicaid 90-day regulation for timely claims submittal is applied to the end date of service (the “through” date in the Statement Dates segment of an 837 Institutional claim).

DRG and ALC claim scenarios with Medicaid as the primary payer:

Scenario 1: The patient moves from DRG to ALC and is then discharged from that ALC period.

The DRG claim is billed from the admission date to the last day the patient was in Acute Care and must have the actual discharge date.
The DRG claim must have a Patient Status Code of 30, “Still a patient”.
The DRG claim must have Occurrence Span Code 75 and the date range the patient was on ALC (in the Occurrence Span Information segment of an 837 Institutional claim).
A separate ALC claim is billed for the time period the patient was on ALC according to the ALC billing guidelines above. Occurrence Span Code 75 and the date range the patient was on ALC must be included.

Scenario 2: The patient moves from DRG to ALC, then back to DRG. The patient is discharged from DRG.

The DRG claim is billed from the admission date to the discharge date.
All the days in the time period are reported as Medicaid full days.
The time period the patient was on ALC is included in the DRG claim using Occurrence Span Code 75 with the date range the patient was on ALC. The ALC period is billed in a separate claim.
The ALC claim is billed as a separate claim, with Occurrence code 75 and the date range the patient was on ALC.
The actual Acute Care admission date is used on the ALC claim.

Scenario 3: There are multiple ALC periods within the DRG date range.

The DRG claim contains the same information as in Scenario 1 or Scenario 2 above.
Multiple entries of the Occurrence Span Code 75 and the corresponding dates are supported in the 837 Institutional claim.

DRG and ALC claim scenarios for Medicaid after Medicare:

Both Medicare Coinsurance and LTR days are still considered Medicare Covered Days and so are included in the number of Medicare Covered Days with the Medicare full covered days (the days before the coinsurance days).

Scenario 1: Medicare covered the entire stay, there is no Alternate Level of Care period, and the only payment due from Medicaid is the Deductible and/or Coinsurance, and/or Life Term Reserve (LTR) amounts.

The claim can be billed from Admission to Discharge. All of the days reported in the loop 2300 Statement Dates segment are also reported as Medicare Covered Days in the loop 2320 Medicare Inpatient Adjudication segment.
Medicare Coinsurance Days are reported in loop 2300, in the Claim Quantity segment with a Qualifier of “CD”.
Lifetime Reserve Days are reported in loop 2320, in the Medicare Inpatient Adjudication segment.
Medicaid will pay the Part A deductible and/or the coinsurance and/or LTR amounts. Although both deductible and coinsurance amounts are reported in the Claim Adjustment segment there is no Lifetime Reserve Patient Responsibility monetary amount supported in the 837 Institutional claim. This is reported as Coinsurance.

Scenario 2: All Medicare Part A coverage including fully covered days, coinsurance days, and Lifetime Reserve Days are exhausted during the Inlier period (before or on the high trim point day):

The claim is billed from the date of admission to the high trim point, showing the days Medicare covered.
The remaining days are reported as Medicaid Non Covered days. Inlier days after Medicare coverage is exhausted are not payable by NYS Medicaid.

Scenario 3 Medicare Part A coverage exhausts in the Outlier period (after the high trim point).

The claim is billed from the date of admission to the last day of Medicare coverage.
Patient Status Code 30, “Still a patient” is used.
The discharge date is reported.
The deductible and/or coinsurance amounts and/or LTR days for the time period that Medicare covered are reported.
The piece that Medicare did not cover is billed to Medicaid as a separate claim, using the real admission date, with the Outlier Rate Code 2956. There will be zero Medicare days and zero amounts paid.
The “0FILL” option must be used in the second claim. Date Element SBR04 in loop 2000B must contain “0FILL”.

Scenario 4: Medicare started coverage after the admission date.

In this scenario, the entire claim is billed as an off line payment by sending a copy of the Medicaid remittance, Medicare EOB, and a cover letter to the Department of Health, suite 6E, 150 Broadway, Albany NY 12204 attn: Nancy Tumey.

ALC and Medicare

All ALC claims are considered non-DRG and therefore the discharge date is only reported if the patient status code is discharged or transferred. If the status code is 30 no discharge date is reported.

Scenario 1: Medicare did not cover the ALC period and the patient was discharged from ALC.

The DRG Inlier (Rate Code 2946) claim is billed from the admission day to the last day the patient was in Acute Care with status code 30.
The Medicare deductible and/or coinsurance and/or LTR days are reported for the Acute Care (DRG) period.
Occurrence Span Code 75 and the date range the patient was on ALC are reported in the Occurrence Span Information segment of loop 2300.
The ALC claim is then billed to Medicaid as a separate claim using the actual Acute Care admission date.
The Statement Dates are the time period the patient was on ALC.
Occurrence Span Code 75 must be entered and the Occurrence Span dates will be the dates the patient was on ALC.
The rate code applicable to ALC is usually 2950 but it could be different.

Scenario 2: The ALC period started after the high trim point.

The DRG claim is billed from admission day to the last day the patient was Acute Care. This claim will have the Inlier Rate Code 2946. The Patient Status Code is 30, “Still a patient”.
The claim will have Occurrence Span Code 75 and the date range the patient was on Alternate Level of Care (ALC) in the Occurrence Span Information segment in loop 2300.
The applicable days are entered. The claim will have Medicaid Covered Days in the Claim Quantity segment (loop2300, QTY*CA) and Medicare Covered Days in the Medicare Inpatient Adjudication segment (loop 2320, MIA segment).
If there are Medicare Coinsurance Days they are reported in an additional iteration of the Claim Quantity segment.
If there are Lifetime Reserve Days they are reported in an iteration of the Claim Quantity segment and in the Medicare Inpatient Adjudication segment
Medicare Deductible, Coinsurance or LTR amounts are claimed.
The ALC claim is then billed to Medicaid using the actual Acute Care admission date.
The statement covered period is the time period the patient was on ALC.
Occurrence Code 75 must be entered and the occurrence span dates should be the dates the patient was on ALC. The rate code is the applicable ALC rate code (usually 2950 but it could be different).

Scenario 3: The patient moved from DRG to ALC and back to DRG and again to ALC (multiple ALC episodes within the DRG dates).

The DRG claim contains the same information as in Scenario 1 or Scenario 2 above.
Multiple entries of the Occurrence Span Code 75 and the corresponding dates are supported in the 837 Institutional claim.

Medicaid with Other (Commercial) Insurance:

The DRG and ALC claims are billed the same as a Medicaid Primary claim with some additional data items.

The days that were covered by the commercial insurance are reported in loop 2320, in the Medicare Inpatient Adjudication segment (the segment name is misleading).
The payments and adjustments received from the prior payer must be reported. If a commercial Insurance deductible is claimed it is entered in the Claim Level Adjustment or Service Line Adjustment segment, depending on how the prior payer adjudicated the claim.
The claims adjudication system will calculate the amount Medicaid would pay as primary payer, subtract the commercial insurance payment, and compare the remainder to the deductible claimed, and then pay the lower amount.
If no commercial insurance deductible is claimed, the system will calculate the amount Medicaid would pay as primary payer, subtract the commercial insurance payment, and pay the balance. If Commercial insurance paid more than Medicaid, the claim will deny for edit 0843, “Calculated amount less than zero”.

Notes and Comments
Created:	July 2, 2006
Last Modified:	October 12, 2006