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Report Description:
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This report shows
line items which appear on non-institutional claims which
carry a CPT-4 match type (C) at the claim level (see REPORT
NOTES below). Due to the way the Duplicate Claims System assigns
match types to claims and sets, this report must be used very carefully.
Users have the option in this report of selecting actual duplicate
claims only. The user may think that the report is showing only
actual duplicate line items identified by the CPT-4 match type criteria.
In fact, the report is showing the line-items of actual (Y)
non-institutional duplicate claims which have been assigned a match
type of CPT-4 (see REPORT NOTES below). As a result, line items
identified using the OTHER match type may appear on this report
along with the line items identified under the CPT-4 criteria which
caused the claim to be assigned the match type of CPT-4. This report
will not show any line items identified under the EXACT or NEAR
match criteria since line items identified using the EXACT and NEAR
match would force the claim(s) to be assigned a higher level match
type than CPT- 4. This report looks for only those actual duplicate
non-institutional claims with a match type of CPT-
4 and then lists the line items on those claims.
This
report can be used by Program Integrity staff to obtain a listing
of the claims carrying a match type of CPT-4 and their associated
line items. Using the Provider Claim Count Report, users can identify
the provider numbers associated with high volumes of non-institutional claims
involving line items whose last two digits of the procedure code
have been changed. Then using the Provider CPT-4 Report and entering
those provider numbers identified, the user can generate a listing
of the non- institutional claims with line item details associated with
those provider numbers.
The fields displayed on this report are: ICN;
Time Stamp; Claim Level User Defined Code; Solicited Indicator;
Set #; Duplicate Flag Indicator; Sponsor ID; Patient ID; Patient
Name; Line Item Match Type; Line Item Number; CPT-4 Code; Amount
Paid CPT-4; PTC Date; and Responsible FI. The report is grouped
by Provider Number and Sub-ID and provides sub-totals for each provider
Sub-ID and grand totals for each provider Tax-ID. The sub-totals
and grand totals sum the number of line items and the total Paid
dollars.
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Report Parameter Options:
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Users may customize
the report by selecting: All “Standard” parameters minus Match Type,
Claim Type, Last Dates, Set Range (Set Owner Type, Claim Set Status,
Adjustments, Date Type, FI, Region) plus Dupe Flag Indicator, Solicited
Indicator, PTC Dates, Responsible FI, Region, Set Level User Defined
Codes, Claim Level User Defined Codes, and Provider Tax ID.
Users
may customize the report by selecting: All claims or actual duplicate
claims only (to be counted as an actual duplicate claim, it must
have a Y dupe flag and be in a Pending, Validate,
or Closed set); status (All, Open, Pending, Closed, Validate);
only sets that have adjustments associated with them; multi-FI sets,
single FI sets, or both; set match type (All, Exact,
Near, Date Overlap, CPT-4, Other); a single processed-to-completion
date or a range of processed-to- completion dates; a single load
date or a range of load dates; one or all FIs; one, several or all
regions within selected FIs. Users may also select one, several
or all Provider Tax ID numbers to be included in the report.
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Report Notes:
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Match types are
applied at the line-item, claim, and set levels based on a hierarchy.
The most stringent match type applicable is assigned at each level.
The hierarchy for institutional claims is as follows: Exact, Near,
Date Overlap and Other. For non-institutional claims, the hierarchy
is as follows: Exact, Near, CPT-4, and Other. For both claim types,
Exact Match criteria is the most stringent with Near Match next. Other
Match is the least stringent. When the Duplicate Claims System identifies
non-institutional potential duplicates, it is doing so at a line item level.
When a line item is identified as a potential duplicate, the system
labels the line item with the Match Type used to identify
it as a potential duplicate. If a non-institutional claim contains
line items identified as potential duplicates using more than one
match type criteria (one line item identified under Exact Match
criteria and another line item under CPT-4 criteria), the system
uses the match type hierarchy and labels the claim with
the most stringent match type appearing on the line items. If the set contains claims labeled with
different match types (one claim labeled ‘Near’ and another labeled
‘CPT-4’), the system uses the match type hierarchy and labels the set with
the most stringent match type appearing on the claims.
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