MedicaidAdministrativeHigh impact
Additional DRG Codes Subject to Prepayment Review
Illinois Medicaid - HFS·IL · Pediatrics, Critical Care·Provider Notice
Effective date
Aug 1, 2004
We identified it
Jun 21, 2026
Summary
Effective August 1, 2004, claims for DRG 386 and DRG 986 (Extreme Immaturity or Respiratory Distress Syndrome) will be subject to prepayment review by the Peer Review Organization. The PRO will verify medical necessity, validate diagnosis/procedure codes, and evaluate quality of care before payment.
Action Required
Before August 1, 2004: Billing team must ensure all claims for DRG 386 and DRG 986 (Extreme Immaturity or Respiratory Distress Syndrome) include complete medical records and proper documentation to support medical necessity. Update billing workflow to flag these DRGs for prepayment review submission to HealthSystems of Illinois (HSI). Failure to provide adequate documentation will result in claim denials.