Outlier payments
A DRG qualifies for outlier payment once the outlier cost stated in their contract is exceeded (provided the paid DRG does not exceed the percent of charges specified in Commercial and Self Funded contracts). Priority Health may make additional reimbursement above the normal DRG to a facility upon written request.
- Meet the criteria. Outlier inpatient claims that exceed the outlier threshold (identified in the contract) will be reviewed for additional payment, as specified in facility contracts. The facility must contact Provider Services, or a Health Management Specialist, to determine whether or not the admission meets outlier criteria. If outlier criteria are not met, Provider Services or the Health Management Specialist will inform the facility that the case will not be considered for review. When we deny a request, we send a letter to the facility instructing them how they can take part in the appeal process.
- Submit documentation. If the criteria are met, the facility will be directed to submit medical documentation to Health Management for review. If outlier criteria is not met, Provider Network Services or Health Management Specialist will inform the facility that the case will not be considered for review. When a request is denied, a letter will be sent to the facility instructing them how they can take part in the appeal process.
- Medicaid: The State of Michigan Medicaid Low Day/Low Cost and High Day/High Cost Outlier Payment Methodology will be used for Medicaid claims when specified in contracts. Medicare outliers In Network will follow same process.
- Medicare: Out Of Network will be paid using the CMS pricer. Any additional payments are subject to medical and quality review procedures.
