ken fan dubai health insurance corporation, dha adjudication rules and... · 2020-08-03 · dubai...
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Ken FanDubai Health Insurance Corporation, DHA
Disclaimer
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This document has been created by or on behalf of the Dubai Health Authority (DHA). It may only be accessed, downloaded and used by Providers and Payers within the Insurance System for Advancing Healthcare in Dubai (ISAHD) network or those intending to enroll in the ISAHD network, and subcontractors of the DHA (each an Authorized User) as part of the ISAHD’s work in the Emirate of Dubai. No other individual or organization may access, download or use it without prior consent from the DHA.
The DHA is the owner or licensee of all intellectual property rights in this document, and this document is protected by copyright laws and treaties around the world. All such rights are reserved.
If the documentation or any information contained within it is used or relied upon by any person other than an Authorized User or by an Authorized User for any reason otherwise than for which it was intended, neither the DHA nor their representatives or agents will be held liable for any loss or damage arising out of such use or reliance, whether foreseeable or not. Unauthorized use may also result in the DHA taking legal action, including bringing claims for damages based on the unauthorized use.
The DHA makes no representations, warranties or guarantees of any kind whether express or implied that the content of this document is accurate, complete or up-to-date. To the extent permitted by law, we exclude all conditions, warranties, representations or other terms which may apply to this document, whether express or implied.
This disclaimer is of immediate effect from the time this document is published.
Agenda
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• DHI Price Regulation Task Force• New DRG Adjudication Rules• New Coding Updates• DRG Outlier Calculator Revisions • Finalizing DRG Negotiation Factors• 3M CodeFinder and Grouper Software• Q&A
DHI Price Regulation Task Force
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Hospitals Insurers
Terms of Reference
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• Develop health insurance adjudication standards and manuals
• Discuss operational health insurance adjudication queries
• Advise on market perspectives in the development of health insurance payment models for:
o Inpatient services
o Long term care
o Day care
o Outpatient services
• Advise on market perspectives in the development of paying for performance program,
including performance measurements and reward mechanism
• Advise on market perspectives in the development of costing standards for health insurance
price regulation
Dubai Health Insurance Adjudication Manual v1.0
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• 11 Adjudication Rules
• Effective as of 1 September 2020
• Updated regularly
Pre-Authorization and Final Submission of DRG Code
• Providers are to submit an initial DRG code Insurers for pre-approval.
• Providers are to update the pre-authorization DRG code within 48 hours of patient discharge
before submitting the claim to the payer.
• Payers are to respond back within 48 hours post receipt of the revised DRG code.
• Payers are not to reject any justifiable revision of DRG code at time of claim submission.
Note:
Discharge date/time is a mandated field with effect from 1 September 2020. It is part of the claim
submission schema indicated as “EncounterEnd”. Please refer to the following link for details:
https://www.eclaimlink.ae/dhd/encounterend.html
Splitting of DRG Payments Between Two Payers Due to Change of Insurer During a Patient Episode
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The following formulas applies:
• Total DRG Payment = Base Rate x Relative Weight (including Outlier and Add-On Payments)
• Total DRG Payment Per Day = Total DRG Payment / Total LOS (exclude NF)
• Insurer A Payment = Total DRG Payment Per Day x LOS (Insurer A) x Negotiation Factor (Insurer A)
• Insurer B Payment = Total DRG Payment Per Day x LOS (Insurer B) x Negotiation Factor (Insurer B)
Billing DRGs for Transfer Cases (Not Within the Same Hospital Group)
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• When a patient is transferred from hospitalA to hospital B, Hospital A submits a DRGclaim that is paid per diem where the firsthospital day is paid at 100% and subsequentdays paid at 50% capped at the DRG inlierpayment. Hospital B submits a full DRGclaim for the episode in Hospital B.
Discharge Medication in DRG Payments
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• DRG payments includes dischargemedication of up to 7 days maximumcalculated from the date of discharge.
Applying Mark-up on Price of Consumables and Drugs for High Cost Add-on Payments
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• Hospital mark ups are not permitted whensubmitting claims with add-on payments.Hospitals are requested to submit the invoicedirectly from the supplier.
Surgical Kits in High Cost Add-on Payments
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• Individual items in surgical kits will need to beseparated and each individual item will need tomeet the add-on payment criterion in order tobe eligible for additional payments.
Insurance Policy Excluded Services and DRG Billing
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• Hospital services that were provided but arenot covered in the insurance policy should notbe reported as part of the DRG submission.Services not covered in the insurance policyshould be settled between patient and hospital.
Royal Suites and VIP Room Charges
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• DRGs provides a standardized payment for theservices provided. Room charges are alreadyincurred in the base rate calculations. Anyadditional room charges will be settledbetween the patient and the hospital. Hospitals,at their discretion, may offer a better roomswithout charging the patient.
Patient Hoteling
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• Patient should be clinically and administrativelydischarged upon the completion of patient care.If the patient decides to continue to stay in thehospital, the patient should be billed separatelyfrom the DRG payments.
Billing Methodology for Paying Community-Based and Visiting Surgeons
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• Clinicians’ bills should be reported as part ofthe DRG claim submission by the hospital.Clinicians will not be billed separately from theDRG claim submission.
Billing Methodology for “Send Out” Services
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• Send out services are those cases where thepatient is accompanied by the hospital toanother facility to receive service. Payments forsend out services should be arranged internallybetween hospital and the facility. The send outservice will not be part of the DRG claim fromthe hospital.
Lesley LauDubai Health Insurance Corporation, DHA
Medical Coding for COVID-19
Code Description
U07.1 COVID-19
Code Description
86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative,single step method (eg, reagent strip); severe acute respiratory syndromecoronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])
86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)(Coronavirus disease [COVID-19])
87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratorysyndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplifiedprobe technique
CPT
ICD-10-CM
New Codes:
Medical Coding for COVID-19
HCPCS
New Codes:
Code Description
86318 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative,single step method (eg, reagent strip);
Code Description
U0001 CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel
U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multipletypes or subtypes (includes all targets)
CPT
Updated Code:
Medical Coding for COVID-19ICD-10-CM Reporting Guidelines:
To report confirmed cases, assign code U07.1 “COVID-19” then followed by the specific respiratory
condition (e.g. pneumonia, acute bronchitis or unspecified acute lower respiratory infection etc.).
Only assign signs and symptoms codes where a definitive diagnosis has not be established.
To report suspected cases, assign Z20.828 “Contact with and exposure to other viral communicable
diseases”.
To report negative cases, assign Z03.818 “Encounter for observation for suspected exposure to other
biological agents ruled out”.
To report screening for asymptomatic cases, assign Z11.59 “Encounter for screening for other viral
diseases”.
To report asymptomatic cases with positive test result, assign U07.1 “COVID-19”.
To report infection during pregnancy, childbirth or the puerperium, assign O98.5x, Other viral diseases
complicating pregnancy, childbirth and the puerperium then followed by U07.1 “COVID-19”.
Medical Coding for COVID-19
CPT and HCPCS Reporting Guidelines:
For infectious agent detection by nucleic, assign 87635 “Infectious agent detection by nucleic acid
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease
[COVID-19]), amplified probe technique”
For antibody detection, assign 86328 “Immunoassay for infectious agent antibody(ies), qualitative or
semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])” or 86769 “Antibody; severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])” for multiple
steps.
For other specified methods, assign U0002 “2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-
19), any technique, multiple types or subtypes (includes all targets)”.
New Covid-19 DSL Codes
DSL CodeProcedureCPT Code
Description
90.13 93000 ECG 12 LEADS equivalent to CPT 93000
90.14 71010 XRAY CHEST PA equivalent to CPT 71010
90.15 86140 C-REACTIVE PROTEIN(CRP) equivalent to CPT 86140
90.16 82728 FERRITIN equivalent to CPT 82728
90.17 83615 LDH equivalent to CPT 83615
90.18 80076 LIVER PANEL equivalent to CPT 80076
90.19 80069 RENAL PANEL equivalent to CPT 80069
90.20 84145 PROCALCITONIN equivalent to CPT 84145
90.21 85025 CBC equivalent to CPT 85025
90.22 85730 PTT equivalent to CPT 85730
90.23 99000 COVID-19 PROCESSING /COLL equivalent to CPT 99000
63.06 Dr. Rounding Fees for Covid-19
New Teleconsultation DSL Codes
DSL Code Description
41 Teleconsultation – GP
42 Teleconsultation – Specialist
43 Teleconsultation – Consultant
44 Teleconsultation – Allied Health
45 Teleconsultation – Psychotherapy (Psychologist)
46 Teleconsultation – Psychiatry (Adult)
47 Teleconsultation – Psychiatry (Child)
DRG Outlier Calculator Revisions
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Version 2.2 Includes:
• 2018 CPT codes
• 2018 HCPCS
• DDC list as of 6 July 2020
• New cost updates
Budget Neutral DRG Negotiation Factor
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Paid Amounts
Patient Share
InlierPayment
Outlier Payment+ Add-On
Payment
If Applicable
=
Fee For Service DRGs
• If this is not the case the negotiation factor needs to be adjusted to ensure this equation is achieved.• Patient share refers to the patient policy limit, not out-of-pocket amounts
Note