DRG uplift

Last updated: Apr. 27, 2022

To help our partners as they care for our Medicare members during this financially challenging time, we're making the following temporary change:

Providing a 20% DRG reimbursement uplift for hospitalized Medicare members with COVID-19

Hospitals will receive a weighting increase of 20% for members diagnosed with COVID-19 and discharged.

The uplift is applicable for claims with COVID-19 discharges between:

  • Jan. 27, 2020 to Mar. 31, 2020 for B97.29
  • Apr. 1, 2020 to the end of the public health emergency—as determined by CMS—for U07.1

The 20% will be added on to the diagnosis-related groups (DRG) payments, without any budget neutrality adjustment.

We'll be holding these claims until we're able to update our payment systems. We anticipate claims will begin paying around May 20. 

Suspending Medicare Advantage sequestration

CMS started sequestration in 2013 as a 2% claims payment reduction to applicable services for Medicare Advantage. We suspended sequestration on May 1, 2020 and at that time began passing along the 2% to providers for services impacted by sequestration. Following CMS's lead, we resumed sequestration on Mar. 31, 2022 on the following schedule:

  • 1% payment adjustment from Apr. 1-Jun. 30, 2022
  • 2% payment adjustment beginning Jul. 1, 2022

There's nothing you need to do—the sequestration will be automatically withheld from your CMS Medicare Advantage payments like it was done prior to COVID-19.

Reprocessing claims

If claims have already processed, we'll reprocess to ensure appropriate payment. 

Priority Health reserves the right to modify these policies should circumstances warrant.