Section title: Requests for Interpretation
RFI #
2349
DRG vs Payment Variance
Description

Does the DRG code reported in the 835 CLP11 position have to support the payment received? Example, we submitted a claim for a payment at the DRG 622 rate. The subsequent 835 received from the payer included the value 622 in the CLP11 position. However, the payment/Allowed Amount reported on the 835 was significantly less than anticipated for DRG 622. Subsequent conversation with the payer disclosed the DRG had been recalculated to DRG 637 and we were paid an amount appropriate for DRG 637.

Response

The TR3 situational rule identifies that CLP11 is required when the claim is adjudicated using a DRG.  The same situational rule applies to CLP12 which is the adjudicated DRG Weight.  RFI 411 outlines the linkage between CLP11 and CLP12.  CLP11 is used to report the DRG used in adjudication.

DOCUMENT ID
005010X221