CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Mapping — Inpatient DRG Reimbursement Mapping

Defines BCBSRI's operational methodology for mapping inpatient claims to MS-DRG and APR-DRG groupers and how those mappings determine inpatient hospital reimbursement; applies to BCBSRI and contracted inpatient hospitals for Commercial and Medicare Advantage products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Mapping — Inpatient DRG Reimbursement Mapping

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionPrior authorization is not applicable for this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AnnualDRG grouper implementation cadence

Not requiredAuthorization requirement

Sep 2024Publication notice

60-day N/ANotification period exception

DRG Mapping and Reimbursement Rules

DRG mapping and reimbursement rules

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Mapping — Inpatient DRG Reimbursement Mapping

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionPrior authorization is not applicable for this policy.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

BCBSRI assigns reimbursement for inpatient acute services based on the weight assigned to the specific mapped DRG and severity level unless the service is reimbursed on a per diem or negotiated case rate as specified in the inpatient provider contract.

BCBSRI updates APR-DRG grouper software periodically to add new ICD-10 diagnosis and procedure codes which are then mapped to APR-DRGs used for commercial reimbursement.

BCBSRI implements the new MS-DRG grouper each October to reference the most current MS-DRG weights for Medicare reimbursement purposes.

If a claim maps to a DRG that became effective after the DRG weight version in the hospital's contract, the MS-DRG claim will be reimbursed based on the weight it was assigned in its initial year, subject to the hospital's contractual provisions.

Benefits and coverage specifics may vary by group and contract; refer to the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for covered services.

Grouper Definitions

MS-DRG (Medicare Severity Diagnosis Related Group)

TermMedicare Severity Diagnosis Related Group (MS-DRG)

DefinitionGrouper version used by BCBSRI to map inpatient claims and determine reimbursement weights for Medicare Advantage and Medicare-related products.

Update cadenceBCBSRI implements new MS-DRG groupers each October to reference the most current MS-DRG weights for Medicare reimbursement purposes.

Reimbursement applicationReimbursement for inpatient acute services follows the weight assigned to the specific mapped MS-DRG and severity level unless reimbursed under a per diem or negotiated case rate in the inpatient provider contract.

Contract provision noteIf a claim maps to a DRG that became effective after the DRG weight version in the hospital's contract, the MS-DRG claim will be reimbursed based on the weight it was assigned in its initial year, subject to contractual provisions.

APR-DRG (All Patient Refined DRG)

TermAll Patient Refined DRG (APR-DRG)

DefinitionGrouper software used for commercial inpatient claims to map ICD-10 diagnosis and procedure codes to APR-DRGs and severity levels for reimbursement.

Update practiceBCBSRI updates inpatient hospital APR-DRG grouper software periodically to add new ICD-10 diagnosis and procedure codes which are then mapped to APR-DRGs used for commercial reimbursement.

Reimbursement applicationReimbursement for inpatient acute services for hospitals follows the weight assigned to the specific mapped APR-DRG and severity level unless the service is reimbursed on a per diem or negotiated case rate in the inpatient provider's contract.

OpenPayer

Payment Policy Mapping — Inpatient DRG Reimbursement Mapping

DRG Mapping and Reimbursement Rules

Groupers and Code Systems

Prior Authorization and Provider Requirements

Grouper Definitions

MS-DRG	Medicare Severity Diagnosis Related Group grouper versions used to map inpatient claims and determine reimbursement weight.
APR-DRG	All Patient Refined DRG grouper mappings for commercial products; used to assign DRG and severity level for reimbursement.
ICD-10	New diagnosis and procedure codes added to grouper software and mapped to DRGs.