Medicaid Bulletin Impacting Re–Admission and ER Payment — Effective July 1, 2020

Department of Medical Assistance Services (DMAS) recently informed hospitals and physicians about mandated reimbursement changes for state fiscal year 2021. These reimbursement changes will apply to traditional Medicaid fee-for-service claims processed by DMAS and managed care claims processed by Medicaid managed care organizations, including Optima Health.

DMAS recently informed hospitals and physicians about mandated reimbursement changes for state fiscal year 2021. These reimbursement changes will apply to traditional Medicaid fee–for–service claims processed by DMAS and managed care claims processed by Medicaid managed care organizations, including Optima Health.

As directed by DMAS, Optima Health will implement these changes effective July 1, 2020. We encourage you to review the Medicaid Bulletin in its entirety which will be sent to you directly and will also be accessible on the DMAS website.

The Optima Health claims processing system will be updated to meet the new DMAS requirements as indicated below:

  1. Inpatient Readmission Claims — Effective July 1, the Hospital Review Team will determine if the claim should be processed at a 50% reduction. The adjustment code 48GR will be indicated with the description: DMAS 6-30 days Readmission Reduction.
  2. Emergency Room Facility claims — Claims system updates will implement on July 9. Appropriately billed claims submitted prior to the implementation date will be reprocessed.
  3. Emergency Room Physician Claims — Claims system updates will implement on July 13. Appropriately billed claims submitted prior to the implementation date will be reprocessed.

After any applicable reprocessing, should you disagree with a determination made by Optima Health, you may be eligible to appeal the determination depending on the terms of your provider agreement.

Please contact your Optima Health contract manager if you have questions related to these changes.