ClaimCheck[
]?[] is a comprehensive code-auditing tool that we use to
evaluate the relationships between procedure codes submitted on the CMS-1500
claim form (or equivalent electronic format). Claims are edited by
ClaimCheck[
]?[] to ensure that correct coding rules and guidelines
are used. Please note the following information.
[
]Recent upgrade[
]
In an effort to maintain an enhanced level of transparency, the
ClaimCheck[
]?[] software has been upgraded from version 9.0.48 to
9.0.49 effective May 21, 2012. This upgrade applies to all contracted providers
who deliver professional services to members and bill by way of the CMS-1500
claim form or equivalent electronic format. Upgrades to ClaimCheck[
]?[] are scheduled twice yearly, typically in the spring and fall. Edits are
based on recommendations (sourced) by various nationally accepted authorities,
including the American Medical Association, CPT[]?[] (Current
Procedure Terminology), Centers for Medicare & Medicaid Services, and national
specialty societies.
[]Clarifying edits for reprocessed or adjusted claims[
]
ClaimCheck[]?[] and Clear Claim ConnectionTM are updated
regularly for consistency with medical and claim payment policy, new procedure
codes, current health care trends, and/or medical and technological advances.
ClaimCheck[]?[] clinical relationship logic is applied based on the
date a claim is processed, reprocessed, or adjusted in our claims processing
system. This logic is not applied based on the date the service was performed.
Therefore, claims that are reprocessed or adjusted for any reason may receive a
different editing outcome from ClaimCheck[]?[] based on the clinical
relationship logic that is in effect at the time the claim adjustment occurs.
Notwithstanding the foregoing, it is understood that a specific claim payment
policy may supersede the terms of ClaimCheck[]?[] with respect to
the subject of that claim payment policy only.
Detailed disclosures of all ClaimCheck[]?[] code edits are available
through Clear Claim Connection[]TM[], which
is accessible through the NaviNet[]?[] web portal 24 hours a day, 7
days a week. If you have any questions about ClaimCheck[]?[] or
Clear Claim Connection[]TM[], please contact
your Network Coordinator or Hospital/Ancillary Services Coordinator.
[]CPT copyright 2010 American Medical Association. All
rights reserved. CPT is a registered trademark of the American Medical
Association. The AMA assumes no liability for data contained or not contained
herein.[
]
[]NaviNet[]?[] is a registered trademark of
NaviNet, Inc.[
]