DRG uplift and suspending Medicare Advantage sequestration 

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

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:

  • January 27, 2020 to March 31, 2020 for B97.29
  • April 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. From May 1, 2020 to Dec. 31, 2020, we'll be suspending sequestration and passing along the 2% to providers for services impacted by sequestration.

Reprocessing claims

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

Due to the accelerated timeframes in which CMS changes were made, we’ll audit claims in May that may be impacted by these scenario to ensure appropriate payment.

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