APR-DRG PAYMENT SYSTEM
Home State Health is pleased to announce that, starting with July 1, 2025 discharges, we will transition to MO HealthNet’s new All Patient Refined Diagnosis Related Groups (APR-DRG) payment system for acute hospital inpatient services for Medicaid members. This change aims to enhance payment accuracy, better align payment with patient needs, and meet national standards.
As we transition to the APR-DRG payment methodology, Home State Health will meet all state contract requirements and follow MO HealthNet's guidelines and calculators. We'll also adhere to national coding standards, including the ICD-10-CM Official Guidelines for Coding and Reporting, to make sure everything is accurate and up to date. Home State Health’s DRG payments will be adjusted for hospital-specific contract requirements and the MO HealthNet hospital tax.
Home State Health will begin processing claims using APR-DRG on or around 60 days after final state guidance is posted. Home State Health will reprocess per diem paid claims for discharges on or after July 1st shortly after this transition.
All inpatient stays will still need prior authorizations. For emergency inpatient admissions, hospitals can submit prior authorization requests up to one business day after the admission starts.
All inpatient stays are subject to MO HealthNet's Health Care Acquired Condition (HCAC) requirements, including use of the appropriate Present on Admission (POA) indicator for each submitted diagnosis codes. Home State Health may reduce or recoup claim payment if a condition is preventable, resulting in additional hospital services not otherwise needed and/or lengthened hospital stays.
MO HealthNet Exceptions to APR-DRG Payments:
Home State Health reimburses the following hospital types using MO HealthNet’s per diem rates. Home State Health’s per diem payments will be adjusted for hospital-specific contract requirements. The MO HealthNet hospital tax is embedded into the per diem rate, so no additional amounts are paid.
- Specialty Pediatric Hospitals
- Standalone Behavioral Health Hospitals
- Long-term Care Hospitals
- Acute Rehabilitation Hospitals
DRG-Related Programs:
Home State Health will implement the following programs by September 2025. If we request additional information, please send it to the address or other location mentioned in the request letter.
- Certain high dollar claims will be identified for review.
- For identified claims, please provide a comprehensive itemized bill and related documentation.
- Upon receipt of the documentation, if the 6 Degrees Health review results in a finding(s), you will receive a letter from them explaining the results. If there is no finding(s), the claim will be processed as billed.
- If you do not respond to the documentation request, no additional reimbursement will be issued.
Claims under review will be paid at the DRG rate, but additional information may be needed for outlier payments. 6 Degrees will send a letter requesting this information. Providers can submit records via mail, fax, or email as outlined in the request letter.
For more information on Clean Claim reviews, please refer to the following Payment Policies on Home State Health’s website: Clinical & Payment Policies | Home State Health
- CC.PI.04 - Clean Claim Reviews
- CC.PI.06 - Cost to Charge Adjustments on Clean Claim Reviews
- CC.PI.10 - Unbundling Adjustments on Clean Claim Reviews
Home State Health will review certain claims before or after payment to ensure the diagnosis and procedure codes match the medical records. This helps confirm that the billing is accurate and supported by the documentation.
- Pre-payment Review: Claims selected for pre-payment review will be denied until the required medical records are submitted.
- Post-payment Review: Cotiviti will send up to three requests for medical records after payment. If records are not submitted within the specified timeframes, the claim will be recouped.
| ACTION | PRE-PAY DRG VALIDATION | POST-PAY DRG VALIDATION |
|---|---|---|
| Entity | Home State Health | Cotiviti |
| Summary | Prepay medical record validation of submitted DRG | Post-pay medical record validation of paid DRG |
| Address | Home State Health P.O. Box 4050 Please include a copy of the request letter with your submission. | Cotiviti 731 Arbor Way |
| Fax | 1-866-390-4429 | 1-800-615-2809 |
| Website | www.homestatehealth.com | www.cotiviti.com |
| Phone number | Home State Health: Show Me Healthy Kids: | Cotiviti |
| Appeal submission | Home State Health Plan Attn: Claim Appeal Fax: 1-833-641-0887 |
Neither Home State Health nor Cotiviti will cover costs for copying or mailing claim-related documents. Please let any third-party vendors know how to bill your facility for these charges.
Additional Information:
Hospitals are not required to submit interim claims; however, they may do so if a stay exceeds 30 days or if they otherwise choose to do so. Interim claims are paid as full claims and are reconciled upon receipt of the final bill for the stay.
Per Diem Payments: Please submit interim claims subject to per diem payments (i.e., hospital admissions with discharge dates on or before June 30, 2025), with Type of Bill (TOB) 112, 113, and/or 114 as appropriate for the stay.
DRG Payments: Please submit claims subject to DRG payments (i.e., most acute hospital admissions with discharge dates on or after 7/1/2025) as follows:
- Interim stay claims: submit with TOB 112, 113, and/or 114 as appropriate for the stay.
- Final claims: submit corrected claims that include all covered days from admission through discharge using TOB 117. Upon receipt of corrected claims, Home State recoups prior interim payments and renders a final DRG payment for the entire inpatient admission.
For more information and resources to help with this transition, please visit Home State Health's provider page. There, you'll find:
- Health plan staff contact and availability information
- Provider Manual
- Payment policies
- Utilization Management criteria
- Grievance and appeals resources
If you have any questions, need additional resources, or would like to request a printed copy of any materials, please contact Home State Health at 1-855-694-4663.