ForwardHealth currently uses the Medicare Severity Diagnosis Related Group (MS-DRG) classification system to calculate pricing for inpatient hospital claims. The DRG system covers acute care hospitals and critical access hospitals. The DRG pricing system uses the Centers for Medicare and Medicaid Services (CMS) DRG grouper developed for and used by Medicare, with enhancements for newborn DRGs and mental disease and disorder DRGs.
The MS-DRG Grouper version 33 was implemented on October 1, 2015, and is effective through December 31, 2016. The grouper is a computer software system that classifies a patient's hospital stay into an established DRG based on the diagnosis and procedures provided to the patient.
ForwardHealth will implement the All Patient Refined Diagnosis Related Group (APR DRG) classification system to calculate pricing for inpatient hospital claims, Medicare crossover claims, and HMO encounters with dates of discharge or "To" dates of service (DOS) on and after January 1, 2017. The APR DRG classification system will replace the MS-DRG classification system. The MS-DRG classification system will remain effective for inpatient hospital claims, Medicare crossover claims, and HMO encounters with dates of discharge or "To" DOS before January 1, 2017.
The DRG rates and weights are updated and published annually.
Special provisions for hospital services exempt from DRG are included in the Inpatient Hospital State Plan.
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