Claims Processing Procedures
Chapter 8
Section 9
Duplicate Payment Prevention
Revision:
Each claim must be checked for duplicate
billing to prevent erroneous expenditures. Duplicate detection requires
both automated and manual procedures. Following are procedures for
the prevention of duplicate payments. If a contractor believes alternative
procedures will meet the requirements it may request approval of
such alternative procedures from Defense Health Agency (DHA), at
least 30 calendar days prior implementation.
1.0 Automated
Duplicate Checking - Individual Providers
Each
line item on a claim must be checked for duplication against claims
processed and claims in process for that beneficiary, as well as
against other line items on the same claim. At a minimum, the following
fields shall be compared:
• Name/Identification.
• Dates of Service
(individual dates or inclusive dates).
• Provider Number.
• Procedure Code.
• Place of Service
(see
paragraph 4.0 for categories).
• Submitted Charge.
1.1 Exact Duplicate
Matches on all five fields (exact date(s) of
service, provider number, procedure code, place of service, submitted
charge) with completed or in-process claims shall be denied without
clerical intervention. If the exact duplication occurs within a
claim, clerical intervention is required.
1.2 Potential
Duplicate
Two steps are required for automated
detection of potential duplicates:
1.2.1 Step 1
Match
the date of service with:
• Provider Number.
• Procedure Code.
The contractor shall establish an edit which
will identify a delivery billed within eight months of a prior delivery
for the same beneficiary.
1.2.1.1 Option No. 1
The date of service (including overlap of inclusive
dates) shall be first matched with the provider number. If there
is a match on both items, the claim shall be pended for clerical
review. The remaining claims shall be screened in the next sequence
with the date of service, including overlap of inclusive dates,
matched with the procedure code. If there is a match,
the claim shall be pended for clerical review.
1.2.1.2 Option No.
2
The date of service, including overlap
of inclusive dates, shall be first matched with the provider number
the same as in Option 1. Where there is a match, the claim shall
be pended for clerical review.
1.2.2 Step 2
Compare
line items within the same claim. Identify line items as potential
duplicates if:
• Provider numbers agree.
• Dates of service
overlap.
• Procedure
codes are equal.
If
provider numbers do not agree, dates of service that overlap shall
be matched with the procedure code. If these are equal, the line
items shall be identified as potential duplicate services and the
claim shall be pended for clerical review.
2.0 Automated
Duplicate Checking - Institutional Providers
Prevention
of duplicate payments for services billed by institutions requires
a coarser screen and more manual review than professional claims
due to the lack of detailed itemization. The contractor shall compare
the date(s) of service on inpatient and outpatient institutional
claims for a particular beneficiary with those on other institutional
claims processed and in process for that beneficiary. When there
is a match or overlap, the contractor shall pend the current claim(s)
for manual review.
3.0
Manual
Duplicate Checking (Clerical Review)
All
claims identified by the automated system as potential duplicates
require clerical review. Some may require retrieval of the hard
copy or microcopy of the suspected duplicate claim and copies of
previously processed or other in-process claims. The clerical review
shall be used to resolve issues of concurrent care and utilization
of services, as well as the question of duplicate service(s). The
contractor should determine the medical necessity of concurrent
care and/or multiplicity of services.
4.0
Place
Of Service Category
The contractor shall
use Place of Service codes found in the TRICARE Systems Manual (TSM)
for the following categories, at a minimum, for use in duplicate
checking:
• Inpatient Hospital.
• Outpatient Hospital.
• Provider’s Office.
• Patient’s Home.
• Day Care Facility.
• Night Care Facility.
• Nursing Home.
• Skilled Nursing
Facility (SNF).
• Ambulance.
• Other Locations.
• Independent Laboratory.
• Other Medical/Surgical
Facility.
• Residential
Treatment Center (RTC).
• Specialized Treatment
Facility.
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