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Change in Process for DRG Validation

Tuesday, April 30, 2019

Effective July 1, 2019, CarePartners of Connecticut will implement changes to the DRG Validation of Inpatient Hospitals Policy. As part of this change:

  • Providers will no longer be required to submit a corrected claim(s) following a change determination from Cotiviti.
  • If a provider disagrees with a change determination, the provider may submit an appeal to CarePartners of Connecticut within 60 days from the date of the change determination letter. Should a provider disagree with the first-level appeal determination, they may submit a second-level appeal within 60 days of the date of the first-level appeal determination.
  • If a provider does not appeal the change determination within the time frame allowed, CarePartners of Connecticut will adjust the data on the applicable claim(s) to match the change determination. Effective July 1, 2019, CarePartners of Connecticut will correct claims based on Cotiviti’s determination, and submission of a corrected claim will no longer be required.
  • Claims will be adjusted based on the DRG reassignment identified in Cotiviti’s determination.

These changes to the DRG Validation for Inpatient Hospitals Policy will apply to all Cotiviti findings beginning on July 1, 2019, based on the date of the change determination letter.

As a reminder, a change determination by Cotiviti indicates that the medical record request and supporting documentation did not appropriately substantiate the original billing for services. The change determination identifies the proposed DRG reassignment. Contracting providers may not bill the member for any reimbursement differences that result from the audit.

This change is documented in the DRG Validation for Inpatient Hospitals Policy. For questions, please contact Provider Services at 888.341.1508.