[Federal Register Volume 63, Number 250 (Wednesday, December 30, 1998)]
[Notices]
[Pages 71915-71916]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-34478]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Civilian Health and Medical Program of the Uniformed Services 
(CHAMPUS); TRICARE Claimcheck Appeals

AGENCY: Office of the Secretary, DoD.

ACTION: Notice.

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SUMMARY: This Notice sets forth the Department's plans for enhancing 
the appeals process available to providers and beneficiaries for claims 
determinations resulting from TRICARE Claimcheck coding logic.

ADDRESSES: TRICARE Management Activity, Medical Benefits and 
Reimbursement Systems, 16401 E.

[[Page 71916]]

Centretch Parkway, Aurora, CO 80011-9043.

FOR FURTHER INFORMATION CONTACT: Stephen E. Isaacson, Office of the 
Assistant Secretary of Defense (Health Affairs)/TRICARE Management 
Activity, telephone (303) 676-3572, or Ann N. Fazzini, Office of the 
Assistant Secretary of Defense (Health Affairs)/TRICARE Management 
activity, telephone (303) 676-3803.

Background

    Commercial claims-auditing software can be a critical tool in 
addressing fraud and abuse, and commercial systems to detect 
inappropriae coding/billing have been available for several years. Both 
the General Accounting Office (GAO/AIMD-98-91), and the HHS Inspector 
General noted the potential value of such systems as early as 1991. The 
TRICARE Management Activity has taken a phased approach to 
implementation of TRICARE Claimcheck, a customized version of the 
commercially available HBOC/GPG ClaimCheck  software. 
TRICARE Claimcheck contains over 5 million edits that track appropriae 
billing. These edits include unbundling incidental procedures, medical 
visits, pre- and post-operative care, mutually exclusive procedures, 
assistant surgeons, duplicate procedures, and age/sex conflicts. 
Ninety-seven percent of claims pass through TRICARE Claimcheck aduits 
without affecting reimbursement. TRICARE Claimcheck was first used in 
May 1996, and subsequently has been linked with the start of the 
TRICARE regional at-risk managed care support contracts. Prior to 
implementation, there was a less-intensive review system that provided 
only 246 rebundling edits as well as a list of about 250 procedures 
taht were considered to be incidental to another procedure.
    If TRICARE Claimcheck edits result in the denial or rebundling of 
submitted procedure codes, providers may receive lower than expected 
payments, and it is important that providers and beneficiaries have a 
recourse. The General Accounting Office (GAO/HEHS-98-80) in its review 
of TRICARE/CHAMPUS payments to physicians reported some provider 
concern about the TRICARE Claimcheck system. Congress mandated that the 
Department establish an appeals mechanism for providers and 
beneficiaries in section 714 of the National Defense Authorization Act 
for FY 1999. Rulemaking will be initiated to amend 32 CFR 199.10 to 
address TRICARE Claimcheck appeals procedures. We are issuing this 
Notice prior to rulemaking to explain the current appeals process and 
to invite suggestions as to the form the intended TRICARE Claimcheck 
appeals mechanism should take.
    Current TRICARE Claimcheck appeals process: A TRICARE Claimcheck 
appeal is an administrative review of auditing logic. The specific 
dollar amount of an allowance (e.g., the CHAMPUS Maximum Allowable 
Charge) is not formally appealable under TRICARE Claimcheck appeals or 
the appeals procedures established in 32 CFR 199.10. TRICARE Claimcheck 
appeals are made to the TRICARE Managed Care Support Contractor (MCSC) 
that processed the claim. The MCSC recovers the claim and related 
documents to completely review the case and verify the accuracy of the 
application of the TRICARE Claimcheck edits. This process includes: (1) 
verification of the correct procedure code(s) used; (2) review for 
clerical errors that may have resulted in incorrect application of the 
TRICARE Claimcheck edits; (3) medical review; (4) verification that all 
necessary medical documentation has been submitted; and (5) review to 
determine if medical circumstances existed that exceeded the expected 
circumstances upon which the edit is based. A determination that allows 
additional payment amounts results in an adjustment of the claim by the 
contractor with no further action required by the beneficiary or 
provider.
    A corollary of the appeals process involves ongoing communications 
with our MCSC Medical Directors, Lead Agent Medical Directors, and 
professional societies and other organizations who have contacted the 
TMA regarding the appropriateness of specific edits of TRICARE 
Claimcheck. The TMA is working closely with these entities in reviewing 
comments and comparing them to the clinical/medical rationale of the 
TRICARE Claimcheck edit. When consistent with TRICARE policy, changes 
are made in conjunction with the TRICARE Medical Director. This process 
ensures that its edits do not result in improper denial or reduction of 
payment. Suggestions are welcome regarding existing TRICARE Claimcheck 
edits and recommendations for systemic changes to TRICARE Claimcheck. 
Clinical/medical rationale for the suggested change should be included 
for review of the recommendation by the TRICARE Medical Director.
    Intended TRICARE Claimcheck appeals process; As stated above, 
rulemaking will be initiated to further implement the Congressional 
mandate for a more formalized TRICARE Claimcheck appeals process. In 
cases where the current TRICARE Claimcheck appeals process described 
above results in an adverse determination, providers and beneficiaries 
will have a further level of appeal. Providers and beneficiaries will 
be able to submit an appeal along with supporting documentation to the 
TRICARE Management Activity. The requested for appeal will be 
considered on its own merits and a written response will be provided 
for each determination made. The appeal decision issued by the TRICARE 
Management Activity will be the final agency decision on the appeal.

    Dated: December 24, 1998.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 98-34478 Filed 12-29-98; 8:45 am]
BILLING CODE 5000-04-M