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.
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 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
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
Office of Medicaid Policy
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
Coding, Billing and Edits
Providers will be informed of
billing changes through Remittance Advice messages and this
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.
Fall of 2006. There will not be a
To learn more about the Mckesson ClaimCheck software,
please visit these web sites.
www.mckhboc.com - Search for ClaimCheck or
code auditing information.