1. ClaimCheck/ClaimReview Overview
Proprietary to HMHS - not to be disclosed.

2. Agenda Overview What is ClaimCheck What is ClaimReview
Proprietary to HMHS – not to be disclosed.

3. What is ClaimCheck?
ClaimCheck is a review system which audits claims for correct coding of CPT and HCPCS procedure codes.
ClaimCheck is developed and supported by McKesson
According to McKesson:
ClaimCheck is a comprehensive code auditing solution that assists with proper physician reimbursement, automatically evaluating physician claims via sophisticated clinical logic before reimbursement.
Proprietary to HMHS – not to be disclosed.

4. What is ClaimReview?
ClaimReview is a review system which audits claims for correct coding of procedure and diagnosis codes.
ClaimReview is developed and supported by McKesson
According to McKesson:
ClaimReview is an add-on module to ClaimCheck which identifies problematic billing and coding activities.
Proprietary to HMHS – not to be disclosed.

5. Why Does HMHS Use ClaimCheck/ClaimReview?
Policy requirement
TRICARE Reimbursement Manual Chapter 1, Section 3
The contractor shall use a claims auditing software (ClaimCheck or equivalent) to ensure correct coding on all claims
South contract requirement
Section H.13
The contractor will…use ClaimReview in addition to ClaimCheck
Additional benefits
Enforces a TRICARE commitment to correct coding
Tool for maintaining/monitoring program integrity
Influences future care to reduce inappropriate services
Proprietary to HMHS – not to be disclosed.

6. Where is ClaimCheck Used?
HMHS uses ClaimCheck for all claims in the South contract except for:
Inpatient institutional (including SNF)
Physical therapy
Adjunctive dental
Home health PPS
Note: Upon implementation, claims subject to Outpatient Prospective Payment reimbursement will also be excluded from ClaimCheck
Proprietary to HMHS – not to be disclosed.

7. What Does ClaimCheck Do?
ClaimCheck audits claims for correct coding of CPT and HCPCS procedure codes
Specifically, claims are audited for:
Incidental procedures
Medical visits billing with primary procedures
Unbundled services
Mutually exclusive procedures
Services included in pre-operative or post-operative care
Medical need for assistant surgeon
Bilateral and duplicate procedures
Single code edits
Cosmetic surgery
Age discrepancies
Gender discrepancies
Codes that are obsolete, unlisted or experimental
Proprietary to HMHS – not to be disclosed.

8. ClaimCheck Remittance Verbiage
R6CLA – Procedure incidental to another procedure
R6CLB – Medical visit included in allowance for surgical/medical treatment
R6CLC – Procedure rebundled with another procedure
R6CLD – Procedure mutually exclusive to another procedure
R6CLE – Pre-operative care included in surgical allowance
R6CLF – Post-operative care included in surgical allowance
R6CLG – Procedure does not warrant an assistant surgeon
R6CLH – Duplicate service
Proprietary to HMHS – not to be disclosed.

9. Where is ClaimReview Used?
HMHS uses ClaimReview for all claims in the South contract except for:
Inpatient institutional (including SNF)
Physical therapy
Adjunctive dental
Home health PPS
Active duty service members
Note: Upon implementation, claims subject to Outpatient
Prospective Payment reimbursement will also be excluded
from ClaimCheck.
Proprietary to HMHS – not to be disclosed.

10. What Does ClaimReview Do with Claims?
ClaimReview audits claims for correct coding of CPT, HCPCS, and Diagnosis codes. To ensure the program pays for the right service in the right time at the right place.
Specifically, ClaimReview audits for:
Intensity of Service
New Visit Frequency
Diagnosis to Procedure code consistency
Proprietary to HMHS – not to be disclosed.

11. ClaimReview Remittance Verbiage
Intensity of service
P9CTO – Level of care billed not substantiated. Claim line also paid point of service.
P9CRT – level of care billed not substantiated.
New Visit Frequency
P9CFO – Charge reduced to established visit based on previously paid new patient office visit. Claim line also paid point of service
P9CRF – Charge reduced to established visit based on previously paid new patient office visit.
Diagnosis to Procedure
R6CRX – Diagnosis code and procedure code combination non-specific or unrelated.
Proprietary to HMHS – not to be disclosed.

12. Recap: Claim Adjudication What, Why, Where, and How
Automated software tool used during claim adjudication to enforce TRICARE policy and correctly administer the TRICARE benefit
The product contractually required for the South Region
Requires providers to file claims with precise and accurate information
Proprietary to HMHS – not to be disclosed.

13. Why Is Provider Education Necessary?
Coding healthcare claims can be complex
To submit correctly coded claims, it is necessary for claims to be coded by appropriately educated individuals
It is necessary to keep up with current coding guidelines and use current coding books and programs
Behaviors that cause inaccurate billing must be changed/addressed
Proprietary to HMHS – not to be disclosed.

14. Provider Education: Provider Handbook
South Region provider handbook provides detailed explanations of ClaimCheck and ClaimReview
Sent to network and non-network providers every year
Available on the HMHS website as a searchable file
Excerpts from ClaimCheck section
ClaimCheck is an automated product that contains specific auditing logic designed to evaluate professional billing for CPT coding appropriateness and to eliminate overpayment on professional and outpatient hospital claims.
Excerpts from ClaimReview section
ClaimReview [is] an automated module in ClaimCheck designed to check claims for consistency in the diagnosis codes and procedure codes specified.
To avoid necessary claim line denials, please pay particular attention to assign a diagnosis code that represents the reason the procedure is performed, as well as any diagnosis that will impact the treatment.
Proprietary to HMHS – not to be disclosed.

15. Provider Education Provider Remittance
CLAIMCHECK IS A REVIEW SYSTEM EDITING FOR:
Procedure unbundling
Incidental procedures/services
Mutually exclusive procedures
Age and Gender conflicts
Unlisted or cosmetic procedures
CLAIMREVIEW IS A REVIEW SYSTEM EDITING FOR:
Consistency/Accuracy of diagnosis code(s)
Consistency/Accuracy of procedure code(s)
Relationship between diagnosis and procedure
Definitive code selection to the 5 digit
Screening code(s) application where needed
CLAIMCHECK/CLAIMREVIEW RECONSIDERATIONS
If you do not agree with a claim check/claim review denial reason message, please review your documentation before resubmitting a corrected claim. Some denials may be due to inaccurate or incomplete information supplied on the claim. Many times an additional diagnosis to procedure code match or supporting documentation will assist with the claim reconsideration.
For reconsiderations of Claim Check/Claim Review denials, please submit a corrected claim with any additions or supporting documentation to support the claim to the TRICARE Correspondence address.
Corrected claims where additional coding has been supplied can be submitted online at For reconsideration through a medical review, write to:
TRICARE South Correspondence
P.O. Box 7032, Camden, SC
Please provide additional documentation.
The backside of every provider remittance includes a standard explanation of ClaimCheck/ClaimReview edits
Proprietary to HMHS – not to be disclosed.

16. Provider Education: Provider Remittance
Reason code messaging provides education per claim line
R6CLA – Procedure is incidental to another procedure R6CLB – Medical visit included in allowance for surgical/medical treatment
R6CLC – Procedure is rebundled with another procedure
R6CLD – Procedure is mutually exclusive to another procedure
R6CLE – Preoperative care included in surgical allowance
R6CLF – Postoperative care included in surgical allowance
R6CLG – Procedure does not warrant an assistant surgeon
R6CLH – Duplicate service
P9CTO – Level of care billed not substantiated. Claim line also paid point of service
P9CRT – Level of care billed not substantiated
P9CFO – Charge reduced to established visit based on previously paid new patient office visit. Claim line also paid point of service.
P9CRF – Charge reduced to established visit based on previously paid new patient office visit.
R6CRX – Diagnosis code and procedure code combination non-specific or unrelated
Proprietary to HMHS – not to be disclosed.

17. Appeals vs. Reconsiderations
Terms used interchangeably – but are not the same process
Appealable and nonappealable issues define in TOM Chapter 13, Section 3
Examples of appealable issues:
Denials of pre-authorization
Denied referral from a PCM to a specialist
Point of service on emergency care
Examples of non-appealable issues that are considered for reconsideration under the South Contract:
Allowable Charge
For example, ClaimCheck/ClaimReview edits
Retroactive Changes in eligibility
All other point of service issues
Proprietary to HMHS – not to be disclosed.

18. ClaimCheck/ClaimReview Reconsideration: When to Request a Reconsideration
When a provider doesn’t understand or doesn’t agree with a ClaimCheck or ClaimReview reject, what is the next step?
Review the claim and corresponding medical documentation
If additional or more complete coding is available:
Adjust the coding on the claim
Mark “corrected claim” on top of claim form
Submit to PGBA with medical documentation
If more complete coding is not available, a request for reconsideration should be submitted.
Proprietary to HMHS – not to be disclosed.

19. ClaimCheck/Claim Review Reconsideration: How to Request A Reconsideration
Request must be submitted with supporting documentation to justify the codes applied on the original claim
Fax
TRICARE South Correspondence P. O. Box 7032 Camden, SC
Proprietary to HMHS – not to be disclosed.

20. Reconsideration Process
Step 1: Provider submits request for reconsideration with supporting documentation.
Step 2: PGBA reviews to ensure claim was adjudicated according to codes submitted on the claim.
Step 3: If claim was not adjudicated correctly, PGBA adjusts the claim to correct the error.
Step 4: If claim was adjudicated correctly, PGBA forwards the correspondence to HMHS for clinical review.
Continued on next page
Proprietary to HMHS – not to be disclosed.

21. Reconsideration Process (continued)
Continued from previous page
Step 5: HMHS clinical reconsideration first reviews to ensure the claim was coded to fully represent the episode of care, the procedures rendered, and the diagnosis of the patient. If not, education is offered to help the provider submit a corrected claim.
Step 6: If the claim does represent a complete coding scenario and no other code could be used, HMHS then reviews to determine If rendered care is a TRICARE benefit. If not, provider is educated on TRICARE policy.
Step 7: If the correctly coded claim represents an appropriate service, the claim is reprocessed to bypass the ClaimCheck/Claim Review edit.
Proprietary to HMHS – not to be disclosed.

22. Reconsideration Outcomes
PGBA adjusts claim to process correctly
A diagnosis or procedure was not keyed correctly to the original claim
The provider submitted new coding
Inform/educate provider so corrected claim can be submitted
HMHS clinical coders identify additional applicable patient condition in the medical documentation
Inform/educate provider on TRICARE policy
The service rendered is not eligible for separate reimbursement under TRICARE policy
Reprocess claim without ClaimCheck/Claim Review edit
The claim is correctly coded and is eligible for separate reimbursement under TRICARE policy
Proprietary to HMHS – not to be disclosed.

23. Additional Resources www.humana-military.com www.mytricare.com
Routine Correspondence:
Fax:
TRICARE South Correspondence P. O. Box 7032 Camden, SC
Proprietary to HMHS – not to be disclosed.