ClaimCheck Frequently Asked Questions

1. What is ClaimCheck?

ClaimCheck is a software program which is used to assure claims are properly coded using industry standard coding edits. ClaimCheck is designed to detect coding discrepancies automatically. Automated reviews improve accuracy and consistency in claims adjudication and leads ultimately to improved claim turnaround times. ClaimCheck utilizes National Correct Coding Initiatives (NCCI), Current Procedural Terminology (CPT) guidelines, as published by the American Medical Association, and the general standards of medical practice in editing claims. Editing guidelines established by the Centers for Medicare and Medicaid Services are also included in ClaimCheck rules.

2. What is Clear Claim Connection?

Clear Claim Connection provides specific detailed information regarding ClaimCheck’s procedure code auditing software and how it evaluates code combinations during the processing of a claim. Clear Claim Connection allows the HealthChoice Network Provider online access to McKesson’s claims editing rules and clinical rationale used in the auditing software. This is a significant improvement over the current editing software used by FHH. The rationale behind the edits in the current software is not readily available.

3. When will ClaimCheck be implemented?

ClaimCheck will become effective for claims processed on or after July, 10 2006.

This includes claims that are being reviewed subsequent to the initial processing. The previous claims editing system will not be available to HealthChoice after July 9, 2006.

4. If coding combinations are allowed through ClaimCheck that were not allowed under the previous claims editing system, will HealthChoice consider adjusting previous claims?

HealthChoice will not go back and adjust any claims previously adjudicated by the former claims editing system.

5. How will appeals to the ClaimCheck edits be handled?

ClaimCheck appeals will be handled in the same manner as the previous editing system. For appeals, Fiserv Health Harrington should be contacted initially at 1-405 499-4800 or toll free at 1-800-782-5218. If you remain dissatisfied after receiving a response from FHH and you want to continue the appeal process, you may contact HealthChoice Provider Relations at 1-405-717-8970 or 1-800-543-6044. Be prepared to provide medical records for review.

6. If the provider wants to appeal one line item on a claim, will only the single line be reviewed using the ClaimCheck system or will the whole claim be adjudicated and edited again?

If a single line item requires an adjustment the entire claim record will be re-adjudicated and re-edited using ClaimCheck.

7. How will the implementation of ClaimCheck affect Plan benefits?

ClaimCheck has no connection with the HealthChoice Schedule of Benefits and does not determine if a procedure is covered or denied coverage by the Plan. ClaimCheck is used solely to determine if coding is appropriate and correct on claims submitted to HealthChoice.

8. Are all procedure codes edited through ClaimCheck?

All CPT codes are reviewed by ClaimCheck. Only HCPCS codes that have corresponding CPT codes will be reviewed by ClaimCheck.

9. Is it possible to have multiple logins for one facility or provider for Clear Claim Connection?

One login is available per Tax ID nuumber. The Tax ID number is passed from the website to Clear Claim Connection to validate the provider’s authenticity.

10. Consider the following scenario: A claim is paid before the implementation of ClaimCheck. There is a question regarding the processing and payment of the claim that is unrelated to procedure edits. Is there a possibility that the claim will be edited again by ClaimCheck and procedure codes kicked out?

If the claim needs to be adjusted for any reason, the ClaimCheck editing software will be used to review the entire claim and ClaimCheck editing rules will apply.

11. Is the NCCI editing information contained in the ClaimCheck rules updated quarterly as NCCI updates its information?

NCCI edits are also updated quarterly within the ClaimCheck system.

12. Does HealthChoice have the ability to modify the editing rules within ClaimCheck? If it does, have there been any customizations made to ClaimCheck rules specifically for the Plan?

It is very rare that edits are customized to deviate from the standard rules within the editing system. The customizations made in the previous editing system will remain with ClaimCheck.

13. Are the edits contained in ClaimCheck more similar to Medicare’s edits than the previous claims editing system?

ClaimCheck software includes all NCCI Mutually Exclusive and Incidental edits. CMS rules are also used for editing in conjunction with AMA and CPT practices.

14. Can ClaimCheck distinguish between hospital and physician claims?

Edits performed by ClaimCheck will affect procedural codes billed on both CMS-1500 and UB-92 claim forms.

15. How will Medicare claims be affected by the ClaimCheck claims editing system?

ClaimCheck will not be used to edit Medicare primary claims or Medicare supplemental claims.