Presentation on theme: "ClaimCheck/ClaimReview Overview"— Presentation transcript:
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 McKessonAccording 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 McKessonAccording 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 requirementTRICARE Reimbursement Manual Chapter 1, Section 3The contractor shall use a claims auditing software (ClaimCheck or equivalent) to ensure correct coding on all claimsSouth contract requirementSection H.13The contractor will…use ClaimReview in addition to ClaimCheckAdditional benefitsEnforces a TRICARE commitment to correct codingTool for maintaining/monitoring program integrityInfluences future care to reduce inappropriate servicesProprietary 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 therapyAdjunctive dentalHome health PPSNote: Upon implementation, claims subject to Outpatient Prospective Payment reimbursement will also be excluded from ClaimCheckProprietary to HMHS – not to be disclosed.
7 What Does ClaimCheck Do? ClaimCheck audits claims for correct coding of CPT and HCPCS procedure codesSpecifically, claims are audited for:Incidental proceduresMedical visits billing with primary proceduresUnbundled servicesMutually exclusive proceduresServices included in pre-operative or post-operative careMedical need for assistant surgeonBilateral and duplicate proceduresSingle code editsCosmetic surgeryAge discrepanciesGender discrepanciesCodes that are obsolete, unlisted or experimentalProprietary to HMHS – not to be disclosed.
8 ClaimCheck Remittance Verbiage R6CLA – Procedure incidental to another procedureR6CLB – Medical visit included in allowance for surgical/medical treatmentR6CLC – Procedure rebundled with another procedureR6CLD – Procedure mutually exclusive to another procedureR6CLE – Pre-operative care included in surgical allowanceR6CLF – Post-operative care included in surgical allowanceR6CLG – Procedure does not warrant an assistant surgeonR6CLH – Duplicate serviceProprietary 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 therapyAdjunctive dentalHome health PPSActive duty service membersNote: Upon implementation, claims subject to OutpatientProspective Payment reimbursement will also be excludedfrom 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 ServiceNew Visit FrequencyDiagnosis to Procedure code consistencyProprietary to HMHS – not to be disclosed.
11 ClaimReview Remittance Verbiage Intensity of serviceP9CTO – Level of care billed not substantiated. Claim line also paid point of service.P9CRT – level of care billed not substantiated.New Visit FrequencyP9CFO – Charge reduced to established visit based on previously paid new patient office visit. Claim line also paid point of serviceP9CRF – Charge reduced to established visit based on previously paid new patient office visit.Diagnosis to ProcedureR6CRX – 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 benefitThe product contractually required for the South RegionRequires providers to file claims with precise and accurate informationProprietary to HMHS – not to be disclosed.
13 Why Is Provider Education Necessary? Coding healthcare claims can be complexTo submit correctly coded claims, it is necessary for claims to be coded by appropriately educated individualsIt is necessary to keep up with current coding guidelines and use current coding books and programsBehaviors that cause inaccurate billing must be changed/addressedProprietary to HMHS – not to be disclosed.
14 Provider Education: Provider Handbook South Region provider handbook provides detailed explanations of ClaimCheck and ClaimReviewSent to network and non-network providers every yearAvailable on the HMHS website as a searchable fileExcerpts from ClaimCheck sectionClaimCheck 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 sectionClaimReview [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 unbundlingIncidental procedures/servicesMutually exclusive proceduresAge and Gender conflictsUnlisted or cosmetic proceduresCLAIMREVIEW IS A REVIEW SYSTEM EDITING FOR:Consistency/Accuracy of diagnosis code(s)Consistency/Accuracy of procedure code(s)Relationship between diagnosis and procedureDefinitive code selection to the 5 digitScreening code(s) application where neededCLAIMCHECK/CLAIMREVIEW RECONSIDERATIONSIf 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 CorrespondenceP.O. Box 7032, Camden, SCPlease provide additional documentation.The backside of every provider remittance includes a standard explanation of ClaimCheck/ClaimReview editsProprietary to HMHS – not to be disclosed.
16 Provider Education: Provider Remittance Reason code messaging provides education per claim lineR6CLA – Procedure is incidental to another procedure R6CLB – Medical visit included in allowance for surgical/medical treatmentR6CLC – Procedure is rebundled with another procedureR6CLD – Procedure is mutually exclusive to another procedureR6CLE – Preoperative care included in surgical allowanceR6CLF – Postoperative care included in surgical allowanceR6CLG – Procedure does not warrant an assistant surgeonR6CLH – Duplicate serviceP9CTO – Level of care billed not substantiated. Claim line also paid point of serviceP9CRT – Level of care billed not substantiatedP9CFO – 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 unrelatedProprietary to HMHS – not to be disclosed.
17 Appeals vs. Reconsiderations Terms used interchangeably – but are not the same processAppealable and nonappealable issues define in TOM Chapter 13, Section 3Examples of appealable issues:Denials of pre-authorizationDenied referral from a PCM to a specialistPoint of service on emergency careExamples of non-appealable issues that are considered for reconsideration under the South Contract:Allowable ChargeFor example, ClaimCheck/ClaimReview editsRetroactive Changes in eligibilityAll other point of service issuesProprietary 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 documentationIf additional or more complete coding is available:Adjust the coding on the claimMark “corrected claim” on top of claim formSubmit to PGBA with medical documentationIf 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 claimFaxTRICARE South Correspondence P. O. Box 7032 Camden, SCProprietary 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 pageProprietary to HMHS – not to be disclosed.
21 Reconsideration Process (continued) Continued from previous pageStep 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 correctlyA diagnosis or procedure was not keyed correctly to the original claimThe provider submitted new codingInform/educate provider so corrected claim can be submittedHMHS clinical coders identify additional applicable patient condition in the medical documentationInform/educate provider on TRICARE policyThe service rendered is not eligible for separate reimbursement under TRICARE policyReprocess claim without ClaimCheck/Claim Review editThe claim is correctly coded and is eligible for separate reimbursement under TRICARE policyProprietary 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, SCProprietary to HMHS – not to be disclosed.
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