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ClaimCheck^® upgrade and edit clarification

ClaimCheck^® is a comprehensive code-auditing tool that we use to evaluate the relationships between procedure codes submitted on the CMS-1500 claim form (or equivalent electronic format). Claims are edited by ClaimCheck^® to ensure that correct coding rules and guidelines are used. Please note the following information.

Recent upgrade

In an effort to maintain an enhanced level of transparency, the ClaimCheck^® software was upgraded from version 9.0.47 to 9.0.48 effective November 14, 2011. This upgrade applies to all contracted providers who deliver professional services to members and bill by way of the CMS-1500 claim form or equivalent electronic format. Upgrades to ClaimCheck^® are scheduled twice yearly, typically in the spring and fall. Edits are based on recommendations (sourced) by various nationally accepted authorities, including the American Medical Association, CPT^® (Current Procedure Terminology), Centers for Medicare & Medicaid Services, and national specialty societies.

Clarifying edits for reprocessed or adjusted claims

ClaimCheck^® and Clear Claim ConnectionTM are updated regularly for consistency with medical and claim payment policy, new procedure codes, current health care trends, and/or medical and technological advances. ClaimCheck^® clinical relationship logic is applied based on the date a claim is processed, reprocessed, or adjusted in our claims processing system. This logic is not applied based on the date the service was performed. Therefore, claims that are reprocessed or adjusted for any reason may receive a different editing outcome from ClaimCheck^® based on the clinical relationship logic that is in effect at the time the claim adjustment occurs. Notwithstanding the foregoing, it is understood that a specific claim payment policy may supersede the terms of ClaimCheck^® with respect to the subject of that claim payment policy.

Detailed disclosures of all ClaimCheck^® code edits are available through Clear Claim Connection^TM, which is accessible through the NaviNet^® web portal Monday through Saturday from 5 a.m. to 10 p.m. and Sunday from 9 a.m. to 9 p.m. If you have any questions about ClaimCheck^® or Clear Claim Connection^TM, please contact your Network Coordinator.