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ClaimCheck®/ClaimReview—Correct Claims Coding (Article 3) |
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ClaimCheck® is a review system used by Humana Military to audit claims for the correct coding of current procedural terminology (CPT) and health care procedural coding system (HCPCS) procedure codes. ClaimReview is a companion system that audits claims for the correct coding of procedure and diagnosis codes.
Humana Military uses these claims review systems to fulfill contract requirements to ensure correct coding of all TRICARE claims. These review systems are essential in maintaining and monitoring program integrity while reducing the provision of inappropriate services on future claims.
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ClaimCheck/ClaimReview is used for all claims processed under the South contract, except:
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- Inpatient institutional (including a skilled nursing facility)
- Physical therapy
- Adjunctive dental
- Home Health Prospective Payment System
- Active duty service members (ClaimReview only)
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Note: Upon the 2007 implementation of Outpatient Prospective Payment Systems (OPPS), all claims subject to OPPS reimbursement will also be excluded from ClaimCheck/ClaimReview.
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ClaimCheck audits claims for the correct coding of the following CPT and HCPCS procedure codes:
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- Incidental procedures
- Medical visits billed with primary procedures
- Unbundled services
- Mutually exclusive procedures
- Services included in pre-operative or post-operative care
- Medical need for an assistant surgeon
- Bilateral and duplicate procedures
- Single code edits
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ClaimReview simultaneously audits claims for the correct combination of CPT, HCPCS and diagnosis codes—ensuring the program pays for the right number of services at the right time in the right place.
It is important that you and your staff understand the need for correctly coded claims as it can be a complex process. For claims to be coded correctly, it is essential for you and your staff to stay informed about the latest coding guidelines and software.
If there is a discrepancy or disagreement with a ClaimCheck or ClaimReview reject, the following reconsideration process is in place:
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- Review the claim and corresponding medical documentation to determine if additional or more complete coding is available.
- Adjust the coding on the claim.
- Mark “corrected claim” at the top of the claim form.
- Submit the claim to Palmetto Government Benefit Administrators with the corresponding medical documentation:
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Fax: 803-462-3993
- Mail:
TRICARE South Correspondence
P.O. Box 7032
Camden, SC 29020-7032
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If more complete coding is not available, a formal request for reconsideration should be submitted to the fax number or mailing address noted above with supporting documentation for the codes applied on the original claims.
The outcomes from the reconsideration process may include:
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- Errors made during adjudication are corrected
- Information to assist in filing correct claims
- Notification on TRICARE policy
- Customization to prevent future erroneous edits
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Assigning correct codes to claims is a complex, but necessary process that will ensure you receive appropriate reimbursement for your services.
Several resources are available to help you and your staff navigate the ClaimCheck/ClaimReview world. Additional information can be found on the following Web sites:
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Last Reviewed: July 10, 2007
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