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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 9.0.47 to 9.0.48 effective November 14,
2011. 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.
Detailed disclosures of all ClaimCheck? code edits are available through Clear Claim
ConnectionTM, which is accessible through the NaviNet? web portal Monday through Saturday from 5 a.m. to
10 p.m. and Sunday from 9 a.m. to 9 p.m. If you have any questions about
ClaimCheck? or Clear Claim
ConnectionTM, please contact your Network Coordinator.