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Provider Handbook
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Previous Page Table of Contents Next Page
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ClaimCheck®
ClaimCheck Edits
ClaimCheck Reconsiderations
ClaimReview
ClaimReview Reconsiderations |
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ClaimCheck® |
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The TRICARE South Region uses ClaimCheck to review claims on a prepayment basis. ClaimCheck is an automated product that contains specific auditing logic designed to evaluate provider billing for CPT coding appropriateness and to eliminate overpayment on professional and outpatient hospital service claims.
Humana Military updates ClaimCheck periodically with new coding based on current industry standards.
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ClaimCheck Edits |
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Providers should follow CPT coding guidelines to prevent claim denials due to ClaimCheck editing. Any edits made by ClaimCheck will be explained by a message code on the remittance advice. ClaimCheck includes, but is not limited to, the following edit categories:
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- Alternate code replacements
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- Assistant surgeon requirements
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- Duplicate and bilateral procedures
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- Mutually exclusive procedure
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- Preoperative (preop) and postoperative (postop) auditing billed
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The complete set of code edits is proprietary and, as such, cannot be released to the general public. |
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ClaimCheck Reconsiderations |
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ClaimCheck is an automated clinical auditing tool. Participating providers may have claims reconsidered through medical review. Issues appropriate for medical review include:
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- Requests for verification that the edit was appropriately entered for the claim
- Situations in which the provider submits additional documentation substantiating that unusual circumstances existed
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Participating providers interested in a medical review should provide additional information, if necessary. These requests should be mailed to:
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TRICARE South Correspondence
P.O. Box 7032
Camden, SC 29020-7032
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Or, requests may be faxed to:
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| Institutional |
1-803-462-3988 |
| Professional |
1-803-462-3989 |
| Behavioral Health |
1-803-462-3990 |
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You are not permitted to bill TRICARE beneficiaries for services rejected by ClaimCheck. The following claims are not subject to TRICARE ClaimCheck: pharmacy, physical therapy, and inpatient institutional claims. |
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ClaimReview |
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Humana Military utilizes ClaimReview, an automated module in ClaimCheck designed to check 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. |
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ClaimReview Reconsiderations |
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If a line on your claim is rejected, first review your medical documentation for any additional diagnosis and if found, submit it on a “corrected claim.”
If after review, other diagnoses cannot be found, a reconsideration can be requested by sending supporting medical record information to the correspondence address under “ClaimCheck Reconsiderations” earlier in this section. If you have any questions regarding this editing function, you may contact PGBA at 1-800-403-3950.
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