Claim Check
The TRICARE West Region contract uses a version of the McKesson HBOC ClaimCheck®
product
to review non-Outpatient Prospective Payment System (non-OPPS) claims on a
prepayment basis for unbundling. ClaimCheck is an automated product
that contains specific auditing logic designed to evaluate professional billing for CPT coding appropriateness and to
eliminate overpayment.
The current Web-based version (ClaimCheck 8.5) has the ability to read up
to four modifiers on each claim line, as well as the ability to handle HCPCS codes the same way as
CPT codes.
ClaimCheck Edits
You should follow CPT
coding guidelines to prevent claim denials due to ClaimCheck editing. Any
edits made by ClaimCheck will be explained by a message code on the
provider remittance advice.
ClaimCheck includes
the following edit categories:
• Age Conflicts
• Alternate Code Replacements
• Assistant Surgeon Requirements
• Billed Date(s) of Service
• Cosmetic Procedures
• Duplicate and Bilateral Procedures
• Gender Conflicts
• Incidental Procedure
• Modifier Auditing
• Mutually Exclusive Procedure
• Preoperative (pre-op) and Postoperative
(post-op) 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 Appeals
ClaimCheck findings
are “allowable charge determinations” and, as such, are not appealable.
However, participating
providers do have recourse through medical review. Issues appropriate for
medical review
include:
• Requests for verification that the edit
was correctly applied to the claim
• Requests for an explanation of
ClaimCheck auditing logic
• Situations in which you submit
additional documentation substantiating that unusual circumstances existed
