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ClaimCheck®  and ClaimReviewTM  : Important Updates (Article 4)


Humana Military remains dedicated to ensuring the accuracy, timely processing and proper reimbursement of claims. To that end, the TRICARE South Region applies an automated product, ClaimCheck, and its submodule, ClaimReview, to evaluate physician and outpatient hospital surgical claims.
 

ClaimCheck® and ClaimReviewTM have been updated recently to include the evaluation of physical therapy claims. (Note: Pharmacy and inpatient institutional claims remain excluded.)
 

Other recent updates to both ClaimCheck® and ClaimReviewTM software allow providers to incorporate a greater
number of diagnoses per claim, as well as more than one modifier per  line. As a result of this system change,
providers are encouraged to include complete information on claims, which may subsequently produce fewer rejects during the initial claims evaluation process and eliminate the need to submit reconsideration requests.
 

Claim Check
Reviewing claims on a prepayment basis, ClaimCheck contains specific auditing logic designed to evaluate provider billing for [Physician’s] Current Procedural Terminology (CPT) coding appropriateness and to eliminate overpayment on professional and outpatient hospital service claims. Providers should follow CPT coding guidelines to prevent claim rejects due to ClaimCheck® editing. ClaimCheck® includes, but is not limited to, the following edit categories:
  • Age conflicts
  • Alternate code replacements
  • Assistant surgeon requirements
  • Cosmetic procedures
  • Duplicate and bilateral procedures
  • Duplicate services
  • Gender conflicts
  • Incidental procedures
  • Modifier auditing
  • Mutually exclusive procedure
  • Preoperative (preop) and postoperative (postop) auditing billed
  • Procedure unbundlin
  • Unlisted procedures

Humana Military updates ClaimCheck® periodically with new coding based on current industry standards. In the event
ClaimCheck revises a claim, any edits will be explained by a message code on the remittance advice.

Claim Review

ClaimReviewTM, an automated module within the ClaimCheck® product, checks claims for consistency, intensity of
service, and revisit frequency through the codes specified. To avoid unnecessary claim line rejects, be sure to assign a diagnosis code that represents the reason the procedure is performed, as well as any diagnosis that will impact the treatment.

Reconsiderations
Regardless of a ClaimCheck® or ClaimReviewTM edit and subsequent claim line rejection, participating providers may have claims reconsidered through medical review. Participating providers interested in a medical review via reconsideration should provide additional information, such as medical record documentation, if necessary to explain the modifier.
 
A Reconsideration Coversheet/Tipsheet, will assist you in putting together your request on where to fax or mail your request is included on the cover sheet. When submitting a reconsideration request, remember to include:
  • The corrected claim with additional or supporting diagnoses
  • Medical documentation supporting the corrected claim or an explanation supporting the codes originally
    supplied
  • A copy of the remittance page with the reject line and the PGBA-assigned claim number
For more information about ClaimCheck®, ClaimReviewTM or reconsiderations, please refer to the TRICARE Provider Handbook

Other Claims News
For TRICARE providers, Q1 of a calendar year is the time for many important updates, including:
  • CHAMPUS maximum allowable charges (CMACs) for CPT codes are updated annually during Q1.
  • New CPT codes are published, effective January 1.
  • CMAC/TRICARE*allowable charge reimbursement rates are updated.

TRICARE OPPS

At press time, the TRICARE Outpatient Prospective Payment System (OPPS) was awaiting Final Rule and was not yet in effect. Once the Final Rule passes, outpatient service claims may no longer go through ClaimCheck®/ClaimReviewTM evaluation. Humana Military encourages TRICARE South Region providers to check online regularly for important OPPS updates.

  
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Created: December 17, 2007