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What's New

Serving Wyoming EqualityCare Providers

 

 

 

Mckesson ClaimCheck

The content of this web page was last updated on 06/20/2006.

 

Claim Auditing Software Program

In order to keep pace with ever changing medical technology and coding complexities, the Wyoming office of Medicaid, EqualityCare program, will implement a claims auditing software program. This program, called ClaimCheck, is designed by Mckesson to evaluate billing information and coding accuracy on submitted claims.

Background
ClaimCheck is a code auditing tool that works in conjunction with EqualityCare's current claims processing sysem. ClaimCheck's automated method detects coding errors, and documents clinical rationale for payment decisions. The knowledge base for auditing reflects AMA guidelines, CMS Correct Coding Initiative edits, Specialty Society guidelines and industry standards. It contains multiple coding systems, specifically, CPT and ICD-9-CM.

Purpose and Objectives
The purpose of this claims auditing software is to promote correct billing, provide accurate reimbursement, and increase provider payment efficiency.

Affected Providers
Affected providers include all in and out-of-state providers using the 1500 claim form. Services provided by dentists and waiver programs will not be audited by this program.

Covered Services
There may be changes to the list of services covered by the EqualityCare program. These changes will be consistent with AMA and CMS guidelines and will be posted on this web site. Advanced notice will be provided through the Remittance Advice banners.

Office of Medicaid Policy Prevails
Although the new auditing logic is based on clinical criteria and industry standards, differences because of new policy will surface. Where there are differences in policy, Wyoming Medicaid policy will prevail.

Coding, Billing and Edits

Billing Requirements
Providers will be informed of billing changes through Remittance Advice messages and this web site.

Logic
To evaluate claims for coding accuracy, Claimcheck employs Rebundling, Incidental, and Mutually Exclusive logic. Rebundling logic checks for procedure unbundling. That occurs when two or more procedure codes are used to report a service when a single, more comprehensive procedure code exists. Incidental logic checks for certain procedures performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Mutually Exclusive logic checks for procedures that represent overlapping services or that differ in technique or approach but accomplish the same result.

Implementation Date

Fall of 2006. There will not be a transition period

Links

To learn more about the Mckesson ClaimCheck software, please visit these web sites.

www.mckhboc.com - Search for ClaimCheck or code auditing information.

www.ama-assn.org/amednews