MedicaidAdministrativeHigh impact
Enhanced Review Process for DRG Claims
Aetna Better Health of Virginia·VA·Reimbursement
Effective date
May 1, 2024
We identified it
Aug 13, 2026
Summary
Aetna Better Health of Virginia is implementing an enhanced prepayment coding review process for all DRG facility claims with admission dates on or after May 1, 2024. The plan will conduct case history reviews and validate that ICD diagnosis and procedure codes align with the billed DRG to ensure accurate reimbursement.
Action Required
By April 30, 2024: Billing team must prepare for enhanced DRG claim reviews by Aetna Better Health of Virginia. Ensure all inpatient facility claims submitted on or after May 1, 2024 include complete clinical documentation and case history information upfront to expedite review. Verify that all ICD diagnosis codes and procedure codes accurately reflect the appropriate DRG being billed before submission. Update internal processes to flag DRG claims for pre-review validation. Train billing and coding staff on the new requirements. Failure to provide complete clinical information and accurate code-to-DRG mapping will result in claim delays and potential denials.