Claim Check
The TRICARE West Region contract uses a version of the McKesson HBOC ClaimCheck® product
to review non-Outpatient Prospective Payment System (non-OPPS) claims on a prepayment basis for unbundling. ClaimCheck is an automated product that contains specific auditing logic designed
to evaluate professional billing for CPT coding appropriateness and to eliminate overpayment.
The current Web-based version (ClaimCheck 8.5) has the ability to read up to four modifiers on each
claim line, as well as the ability to handle HCPCS codes the same way as CPT codes.
ClaimCheck Edits
You should follow CPT coding guidelines to prevent claim denials due to ClaimCheck editing. Any edits made by ClaimCheck will be explained by a message code on the provider remittance advice.
ClaimCheck includes the following edit categories:
• Age Conflicts
• Alternate Code Replacements
• Assistant Surgeon Requirements
• Billed Date(s) of Service
• Cosmetic Procedures
• Duplicate and Bilateral Procedures
• Gender Conflicts
• Incidental Procedure
• Modifier Auditing
• Mutually Exclusive Procedure
• Preoperative (pre-op) and Postoperative (post-op) Auditing Billed
• Procedure Unbundling
• Unlisted Procedures
The complete set of code edits is proprietary and, as such, cannot be released to the general public.
ClaimCheck Appeals
ClaimCheck findings are “allowable charge determinations” and, as such, are not appealable.
However, participating providers do have recourse through medical review. Issues appropriate for
medical review include:
• Requests for verification that the edit was correctly applied to the claim
• Requests for an explanation of ClaimCheck auditing logic
• Situations in which you submit additional documentation substantiating that unusual
circumstances existed
Requests for review of ClaimCheck edits must be received within 90 days of the date of the remittance advice and are resolved within 45 days of receipt. Participating providers who are registered users
of www.triwest.com/provider and are interested in a medical review should use online claims
correspondence to request consideration on a case- by-case basis. Appropriate attachments with
supporting documentation can be electronically attached to the online claims correspondence.
If online submission is not an option, a letter and copy of the claim may be submitted to:
TriWest Healthcare Alliance Corp.
ClaimCheck Appeal
P.O. Box 77029
Madison, WI 53707-1029
Following medical review, TriWest may override the ClaimCheck edit and allow additional
amounts to be paid.
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