| ClaimCheck
ClaimCheck is a fully automated claims auditing system
that verifies the clinical accuracy of professional
claims. ClaimCheck identifies coding errors in the following
categories:
Multiple code conflicts:
- Procedure unbundling
- Mutually exclusive procedures
- Incidental procedures
- Medical visits, same date of service
- Bilateral and duplicate procedures
- Pre- and postoperative care unbundling
Single code conflicts:
- Age conflicts
- Sex conflicts
- Cosmetic procedures
- Investigational procedures
- Obsolete procedures
Definitions:
- Incidental: Procedures that require
little additional physician resources and/or are integral
to the primary procedure performed. The incidental
procedure will not be reimbursed separately.
- Mutually Exclusive Procedures:
Two or more procedures usually not performed during
the same session for the same patient on the same
day. This includes different procedure code descriptions
for the same types of procedures where only one code
should be billed.
- Primary Procedure: The procedure
with the greatest clinical intensity is considered
to be the primary procedure regardless of billed amounts.
- Unbundling: Two or more CPT codes
are used to describe a procedure where a single, more
comprehensive code, exists that describes the entire
procedure performed. ClaimCheck will rebundle these
procedures to the appropriate code.
Payments:
Payments will be made based on the approprate fee schedules
and ClaimCheck bundling edits.
Reconsiderations:
For reconsiderations of ClaimCheck bundling, please contact your provider services consultant or customer service at (801) 333-2100 or 1 (800) 624-6519.
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