On July 1, 2021, IDHW moved to the APR-DRG reimbursement model and discontinued the prospective review of certain inpatient stays conducted by UM vendor, Telligen. Due to that change, IDHW will be implementing a monthly post payment audit process. As a part of the process, a randomly selected sample of APR-DRG paid claims will be reviewed to either validate DRG coding accuracy or to retrospectively review the medical necessity of the inpatient stay.
A hospital will be notified in writing of claims which have been selected and that are subject to audit that month. If a paid claim is subject to audit the provider will be required to submit medical records as outlined in the audit request. Telligen will conduct these audits on behalf of IDHW.