MedicaidDocumentationHigh impact
Payment & Clinical Policies Effective Sept 1, 2026
Ambetter·NH · Critical Care, General Surgery, Internal Medicine +1 more·Claims & Billing
Effective date
Sep 1, 2026
We identified it
Aug 26, 2026
Summary
NH Healthy Families and Ambetter are implementing stricter documentation and coding requirements for inpatient malnutrition claims effective September 1, 2026. The policy will deny reimbursement for the cost difference between DRGs billed with malnutrition as a major complication/comorbidity (MCC) versus those without, unless documentation meets new criteria. The policy now distinguishes between moderate (non-severe) and severe malnutrition with separate diagnosis guidelines.
Action Required
By August 31, 2026: (1) Billing team must update claim denial/audit logic in billing system to flag inpatient claims with ICD-10 codes E44.0 (moderate malnutrition) and E44.1 (severe malnutrition) as MCC codes for retrospective review. (2) Providers and clinical documentation specialists must ensure all inpatient admissions with malnutrition diagnosis include physician-documented clinical evidence meeting the new Criteria I (moderate) and Criteria II (severe) guidelines—specific documentation must detail malnutrition severity, supporting clinical findings, and treatment plan. (3) Billing staff must establish a process to validate malnutrition documentation before claim submission to prevent denials for missing or insufficient documentation. (4) Contact Provider Services (1-866-769-3085) to obtain full policy details on Criteria I and II documentation requirements. Failure to comply will result in claim denials and recoupment of cost differences between MCC and non-MCC DRG payments.