Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC)
Chapter 13
Section 5
Medical Review And Allowable
Charge Review Under the Outpatient Prospective Payment System (OPPS)
Issue Date: July 27, 2005
Authority: 10 USC 1079(j)(2) and 10 USC 1079(h)
Revision:
1.0 APPLICABILITY
This policy is mandatory for the reimbursement
of services provided either by network or non-network providers.
However, alternative network reimbursement methodologies are permitted
when approved by the Defense Health Agency (DHA) and specifically
included in the network provider agreement.
2.0 ISSUE
To describe the medical review and allowable
charge review of hospital outpatient claims.
3.0 POLICY
3.1 Medical
review under the hospital OPPS.
3.1.1 The methodology of review
for outpatient claims does not change under the OPPS.
3.1.2 The goal
of medical review is to identify inappropriate billing and to ensure
that payment is not made for noncovered services. Contractors may
review any claim at any time, including requesting medical records,
to ensure that payment is appropriate.
3.2 All
OPPS review of claims processing with the exception of the Inpatient
Only Procedures List, would be considered allowable review.
4.0 Effective
Date
May 1, 2009.
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