The TRICARE South Region uses ClaimCheck® to review claims on a prepayment basis. ClaimCheck is an automated clinical auditing tool 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.
ClaimCheck Edits
Providers should follow CPT coding guidelines to prevent ClaimCheck editing from resulting in claim denials. 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:
- Age conflicts
- Alternate code replacements
- Assistant surgeon requirements
- Cosmetic procedures
- Duplicate and bilateral procedures
- Duplicate services
- Gender conflicts
- Incidental procedures
- Modifier auditing
- Mutually exclusive procedures
- Preoperative (preop) and postoperative (postop) auditing billed
- Procedure unbundling
- Unlisted procedures
The complete set of code edits is proprietary and, as such, cannot be released to the general public.
ClaimCheck Reconsiderations
Participating providers may have claims reconsidered through medical review. Issues appropriate for medical review include:
- 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
Participating providers interested in medical reviews should provide additional information, if necessary. These requests should be mailed to:
TRICARE South Correspondence
P.O. Box 7032
Camden, SC 29020-7032
Requests may also be faxed to:
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Institutional Provider
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1-803-462-3988 |
Professional Provider
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1-803-462-3989 |
Behavioral Health Provider
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1-803-462-3990 |
You are not permitted to bill TRICARE beneficiaries for services rejected by ClaimCheck.
ClaimReview
Humana Military utilizes ClaimReview
TM, 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 rejections, assign a diagnosis code that explains why the procedure is performed, as well as any diagnosis that will impact the treatment.
ClaimReview Reconsiderations
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 other diagnoses are not found after review, you may request a reconsideration 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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