 | Clear Claim Connection™ is a web-based code auditing reference tool designed to mirror how Claim CheckŪ evaluates code combinations during the auditing of professional claims. This tool enables AmeriHealth to disclose its claim auditing rules and clinical rationale inherent to the Claim CheckŪ system. By accessing this tool the user can view the justifications and clinical rationale on why code combination logic was applied to a professional claim processed in the base claims processing system (MHS).
Clear Claim Connection™ is now available for providers through the NaviNetSM Portal. More information on NaviNetSM can be found on the For Providers section of this website.
Claims Adjudication
Claims adjudication is a combination of multiple independent factors including:
- The base claims processing system (MHS), which houses such things as benefits, pre-authorization requirements, and fee schedules
- Claim CheckŪ, which houses mainly code-to-code clinical logic relationships
- Policies affecting claims payment
- Independent claims examiner or medical director review
The most common types of Claim CheckŪ clinical relationship logic are:
- Incidental Procedures (multi-code): this edit occurs when a procedure is performed at the same time as a more complex primary procedure and is clinically integrated to the successful outcome of the primary procedure (one procedure clinically integral to another).
- Procedure unbundling (multi-code): the re-bundling edit occurs when two or more procedure codes are used to report a service when a single, more comprehensive procedure code exists that more accurately represents the service performed by a provider.
- Mutually Exclusive Procedures: this is generally the combination of procedures that differ in technique or approach but lead to the same outcome. Claim CheckŪ identifies the overlapping services when a provider bills separately for two or more procedures that are usually not performed during the same patient encounter on the same date of service.
The information provided in Clear Claim Connection™ only speaks to the clinical editing logic housed within Claim CheckŪ. Clear Claim Connection™ will not give the final outcome of claims adjudication. Therefore, Clear Claim Connection™ should only be used for validating the clinical rationale of confirmed Claim CheckŪ clinical relationship logic. | |