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 was upgraded from version 9.0.50 to 9.0.51 effective May 13, 2013.
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
ConnectionTM, which is accessible through the
NaviNet® web portal 24 hours a day, 7 days a week.</p<
If you have any
questions about ClaimCheck® or Clear Claim
ConnectionTM, please contact your Network Coordinator.
NaviNet? is a
registered trademark of NaviNet, Inc.
CPT copyright 2012 American Medical
Association. All rights reserved. CPT is a registered trademark of the American
Medical Association.