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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