ClaimCheck Frequently Asked Questions

1. What is ClaimCheck?

ClaimCheck is a software program which is used to assure claims are properly coded using industry standard coding edits. ClaimCheck is designed to detect coding discrepancies automatically. Automated reviews improve accuracy and consistency in claims adjudication and leads ultimately to improved claim turnaround times. ClaimCheck utilizes National Correct Coding Initiatives (NCCI), Current Procedural Terminology (CPT) guidelines, as published by the American Medical Association, and the general standards of medical practice in editing claims. Editing guidelines established by the Centers for Medicare and Medicaid Services (CMS) are also included in ClaimCheck rules.

2. What is Clear Claim Connection?

Clear Claim Connection provides specific detailed information regarding ClaimCheck’s procedure code auditing software and how it evaluates code combinations during the processing of a claim. Clear Claim Connection allows the HealthChoice Network Provider online access to McKesson’s claims editing rules and clinical rationale used in the auditing software.

3. How will appeals to the ClaimCheck edits be handled?

HealthChoice follows a strict process in the handling of provider appeal requests. Please consult the Provider Manual for details regarding the appeals and dispute resolution process.

4. How will the implementation of ClaimCheck affect Plan benefits?

ClaimCheck has no connection with the HealthChoice Schedule of Benefits and does not determine if a procedure is covered or denied coverage by the Plan. ClaimCheck is used solely to determine if coding is appropriate and correct on claims submitted to HealthChoice.

5. Are all procedure codes edited through ClaimCheck?

All CPT codes are reviewed by ClaimCheck. Only HCPCS codes that have corresponding CPT codes will be reviewed by ClaimCheck.

6. Is it possible to have multiple logins for one facility or provider for Clear Claim Connection?

One login is available per Tax ID number. The Tax ID number is passed from the website to Clear Claim Connection to validate the provider’s authenticity.

7. Is the NCCI editing information contained in the ClaimCheck rules updated quarterly as NCCI updates its information?

NCCI edits are also updated quarterly within the ClaimCheck system.

8. Does HealthChoice have the ability to modify the editing rules within ClaimCheck? If it does, have there been any customizations made to ClaimCheck rules specifically for the Plan?

It is very rare that edits are customized to deviate from the standard rules within the editing system.

9. Are the edits contained in ClaimCheck similar to Medicare’s edits?

ClaimCheck software includes all NCCI Mutually Exclusive and Incidental edits. CMS rules are also used for editing in conjunction with AMA and CPT practices.

10. Can ClaimCheck distinguish between hospital and physician claims?

Edits performed by ClaimCheck will affect procedural codes billed on both CMS-1500 and UB-04 claim forms.

11. How will Medicare claims be affected by the ClaimCheck claims editing system?

ClaimCheck will not be used to edit Medicare primary claims or Medicare supplemental claims.