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MS-DRG Prepayment Coding Edits

October 1, 2021

WellCare utilizes clinical coding software to perform industry standard claim validity checks in accordance with all applicable rules and regulations which have been set forth by CMS (such as the National Correct Coding Initiative (NCCI) and the National Physician Fee Schedule Manuals), the American Medical Association (AMA) and Specialty Societies. WellCare uses vendor claim editing software to assist in determining proper coding for Provider claim reimbursement.

In partnership with Optum, WellCare of Kentucky has enhanced its adjudication process and extends claim adjudication to also include an analysis of MS-DRG claims as a whole and/or individual detail for the specific charges in comparison with the medical records. These edits will function like other existing prepayment edits and may result in a request of medical records. The medical record review will determine if the billed DRG is consistent with the medical records provided to Optum and will not be based on medical necessity. Record review determinations will be based on industry standards i.e. AHIMA, ACDIS, AAPC, CMS/Medicare Rules and Regulations, WellCare of Kentucky Payment Policies, etc.

Providers may request reconsideration of any adjustment or denial by submitting a request for reconsideration to WellCare of Kentucky as long as it follows the dispute timely filing guidelines.

The effective date for the MS-DRG specific prepayment edits is November 1st, 2021.

For additional information about our Optum CPI Claims Process, please refer to Claims and Payment Policy: Comprehensive Payment Integrity (CPI) KY Only, Policy Number: CPP-160 (Medicaid), and Comprehensive Payment Integrity (CPI)CPP -136 (Medicare), also located on our Provider web page

Thank you for your partnership.
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Last Updated On: 10/1/2021
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