All Patient Refined Diagnosis Related Group (APR DRG) System Testing

ForwardHealth is offering optional All Patient Refined Diagnosis Related Group (APR DRG) testing to all hospital providers and HMOs from October 24, 2016, through February 10, 2017. Although testing is optional, hospital providers and HMOs are encouraged to test to ensure appropriate processing and pricing of inpatient hospital fee-for-service claims, Medicare crossover claims, and HMO encounters under the APR DRG classification system.

Testing will be conducted using the Supporting External Testing (SET) environment.

Accessing the Testing Environment

The SET environment can be accessed at https://www.forwardhealthsete.wi.gov/

Testers will be prompted to use their current ForwardHealth Portal credentials when accessing the SET environment. Testing accounts were set up automatically, so testers do not need to request special access from ForwardHealth.

If a trading partner will be testing on a provider's behalf but the trading partner does not have access to the SET environment, the provider should send an email to VEDSAPRDRGSupport@wisconsin.gov to request access for the trading partner. The trading partner's Portal username and contact info should be included in the email.

Testing screens in the SET environment are clearly labeled to ensure testers are able to distinguish between the testing and production environments.

Testing Guidelines

The following effective and end dates for the APR DRG system have been adjusted in the SET environment to support testing activities:

• Claims and encounters with "To" dates of service (DOS) or dates of discharge on or before March 31, 2016, will be processed using the Medicare Severity Diagnosis Related Group (MS-DRG) classification system.
• Claims and encounters with "To" DOS or dates of discharge on and after April 1, 2016, will be processed using the APR DRG classification system.

Testers should determine appropriate "To" DOS or dates of discharge for testing transactions based on these dates. Because member eligibility varies, it is recommended that dates indicated on test transactions not extend too far before or after the SET environment-adjusted effective and end dates. Additionally, it is recommended that member eligibility be confirmed prior to testing.

Testers are encouraged to refer to recent claims or encounters they submitted to ForwardHealth and test using modified "To" DOS or dates of discharge that fall into the APR DRG date range.

Testing for claims or encounters requiring prior authorization will not be supported.

Note: Claims or encounters submitted with codes that were updated, changed, or revised as part of the October 1, 2016, national annual code updates may yield unexpected results in SET.

APR DRG Grouper Version

ForwardHealth will use APR DRG version 33 with GPS 2016.3.1, including the October 18, 2016, hot fix, in the SET environment for APR DRG testing.

Testing Questions from Fee-for-Service Providers

Fee-for-service testers should email SET environment questions or technical issues to VEDSAPRDRGSupport@wisconsin.gov. Do not include protected health information or any other personally identifiable information in the email.