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

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Presentation on theme: "ClaimCheck/ClaimReview Overview. Proprietary to HMHS – not to be disclosed.2 Agenda  Overview  What is ClaimCheck  What is ClaimReview."— Presentation transcript:

1 ClaimCheck/ClaimReview Overview

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

3 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.

4 Proprietary to HMHS – not to be disclosed.4 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. What is ClaimReview?

5 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

6 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

7 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

8 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

9 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.

10 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

11 Proprietary to HMHS – not to be disclosed.11 Diagnosis to Procedure  R6CRX – Diagnosis code and procedure code combination non-specific or unrelated. 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.

12 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  Requires providers to file claims with precise and accurate information  The product contractually required for the South Region

13 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

14 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.

15 Proprietary to HMHS – not to be disclosed.15 Provider Education Provider Remittance  The backside of every provider remittance includes a standard explanation of ClaimCheck/Claim Review edits 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:www.mytricare.com TRICARE South Correspondence P.O. Box 7032, Camden, SC Please provide additional documentation.

16 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

17 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

18 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.

19 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

20 Proprietary to HMHS – not to be disclosed.20 Reconsideration Process Step 1: Provider submits request for reconsideration with supporting documentation.documentation Continued on next page 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.

21 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.

22 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

23 Proprietary to HMHS – not to be disclosed.23 Additional Resources      Routine Correspondence:  Fax:  TRICARE South Correspondence P. O. Box 7032 Camden, SC


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