Acute Care Hospitalizations Payment Policy - Sepsis Diagnosis

Date: 07/01/22

Superior HealthPlan conducts retrospective reviews to validate appropriate billing and payment of many health care services, including acute care hospitalizations reimbursed using Diagnosis Related Grouping (DRG) payment methodology.

A payment policy has been implemented to communicate Superior’s documentation requirements for purposes of DRG reimbursement for sepsis acute care inpatient claims.

The policy has been added, and is posted on Superior’s Clinical, Payment and Pharmacy Polices webpage for reference and use for retrospective claim reviews.

POLICY	EFFECTIVE DATE	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Acute Care Inpatient Hospital Claims - Sepsis Diagnosis (CC.PP.073)	07/01/2022	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Health Insurance Marketplace (Ambetter from Superior HealthPlan)	The policy clarifies the correct coding on claims billed with a sepsis diagnosis, not to include sepsis screening for which a sepsis diagnosis is not confirmed

To review all payment policies, please visit Superior’s Clinical, Payment and Pharmacy Polices webpage.

For questions or additional information, please contact Superior Provider Services at:

• 1-877-391-5921 Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Wellcare By Allwell (HMO DSNP)
• 1-877-687-1196 Ambetter from Superior HealthPlan(Health Insurance Marketplace)