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August 1, 2013 - July 31, 2014
1. Will there be documentation supplied by DPW to explain the specific codes impacted by this as well as when the rules are applied?
Response: The Department issued Medical Assistance (MA) Bulletin 99-08-17 on October 20, 2008. The bulletin contains specific examples to explain how ClaimCheck® edits impact claims processing. The bulletin also identifies the different entities and sources which provide the clinical rationale to support ClaimCheck® edits. Any services covered by the MA Program Fee Schedule can potentially be impacted however an attachment to the bulletin, Attachment A - ClaimCheck® Claims Criteria, identifies the specific types of claims and services that are included and excluded from editing requirements.
2. What will be the impact on outpatient rehab facilities be as a result of implementing ClaimCheck®?
Response: Services provided by outpatient rehabilitation facilities will be subject to ClaimCheck® audits unless the types services being rendered are excluded from editing requirements. For example, if services are related to behavioral health, then the claim will be excluded from ClaimCheck® editing. Please refer to Medical Assistance (MA) Bulletin 99-08-17, Attachment A – ClaimCheck® Claims Criteria, for a list of exclusions.
3. What percentage of billing errors is the ClaimCheck® software expected to detect?
Response: It is difficult to say what percentage of billing errors will be detected by ClaimCheck®. The percentage can vary and will be impacted by factors such as the procedure code/s and procedure code combinations billed on a current claim or history claim, the accuracy of the information reported and whether or not the reported information is consistent with nationally recognized clinical guidelines, industry standards and coding guidelines.
4. Will the entire claim reject or, will MA pay by line item as they do now after ClaimCheck® is implemented?
Response: MA will continue to pay at the service line item level. Error Status Code (ESC) messages will be returned and displayed on a Remittance Advice (RA) with a description.
5. Will there be NEW ClaimCheck® error status codes for easy identification with short and/or long descriptions?
Response: The Department's website was updated to display all of the new ClaimCheck Error Status Codes (ESC) numbers along with the short description and long description. The ESC ranges are 3500 through 3599, 3602 through 3606, and 9018.