[Federal Register: December 30, 1998 (Volume 63, Number 250)] [Notices] [Page 71915-71916] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr30de98-49] ----------------------------------------------------------------------- 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. ----------------------------------------------------------------------- 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