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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