The DCS performs several functions
for the maintenance of the DCS databases. First, it identifies,
selects, and extracts potential duplicate claims from the TRICARE
DCS-TRICARE Encounter Data (TED) Version database. It then groups
potential duplicate claims into sets and stores these claims in
the DCS Active database. Subsequently, it identifies adjustment
and cancellation transactions processed by the TED system associated
with claims in the DCS Active and History databases and attaches
these adjustment transactions to their associated sets. In attaching adjustment/cancellation
TED records to their associated sets, the system enables users to
verify that duplicate payment records have been removed from the
TED database.
The DCS performs these functions
separate and apart from the proprietary, claims processing systems
maintained and operated by the contractors, TRICARE Dual Eligible
Fiscal Intermediary Contract (TDEFIC) contractor, and the TRICARE
Overseas Program (TOP) contractor. Proprietary claims processing
systems maintain claim and encounter processing histories which
document the activities associated with the processing and payment
of claims and encounters. These systems generate TEDs for submission
to the Defense Health Agency (DHA). TEDs reflect specific claim/encounter
processing activity and document health care services and associated
payment actions. TEDs are in a uniform format to permit claims processing
data from various contractors to be integrated into a single database.
Contractors are required to
prevent duplicate claim payments. Despite a variety of automated
and manual controls established for this purpose, duplicate payments
are made. These duplicate payments, appearing as duplicate TEDs,
are detectable by DHA. When duplicate payments are identified, contractors
are expected to initiate recoupment action. Upon receipt of the
refunds or offsets, adjustment TEDs should be submitted to reflect
the recoupments. When adjustments are added to the TED database,
the duplicate payments are corrected, and the duplicate conditions
are removed from the TED database.
The correction of the TED database
is a critical function of the DCS. Not only do duplicate TEDs represent overpayments,
their very existence in the TED database skew statistics and reduce
the confidence of analyses and projections based on this data. Data
integrity is compromised if the database is not purged of TEDs representing duplicate
payments.
The DCS is not intended to
replace or substitute for contractor developed, maintained, and
operated duplicate detection and resolution activities within their
own claims processing systems. The DCS does not pretend to capture
all potential duplicate conditions. If it did, the volume of claim
sets would soon become unmanageable. The DCS is an adjunct to contractor
systems. It detects and displays most common duplicate conditions
but not all.
The contractor shall also employ
their own systems to prevent, detect, and resolve duplicate payment
conditions.
1.0
Source
Of Duplicate Claims Data
The following
describes how TEDs become DCS sets and what happens to these sets
over time within the DCS.
1.1 Contractors
submit TEDs approximately daily. The TEDs are maintained on a TED
database.
1.2 On a monthly basis, DHA reads
the TED database and compares the TEDs received during the previous month
to TEDs received during the previous 12 months of TED Net data to
identify potential duplicate claims. The identified potential duplicate
TEDs become the DCS monthly extract.
1.3 DHA also
processes the daily TED data received from the contractors and extracts
any TED adjustments and cancellations to TEDs previously identified
as potential duplicates in a monthly extract and that reside in
the DCS. These extracts become the DCS daily extract.
1.4 DHA transfers the extracts
to the Database 2 (DB2) Server platform where they are processed
and placed into the DCS Active database.
1.5 DCS users
work the sets in the DCS Active database.
1.6 After
a specified period of time, the DCS sets are deleted from the DCS
History database.
1.6.1 The DCS databases receive TED
data through two extracts. The first extract is performed monthly,
when TEDs submitted by contractors during the previous month are
compared with TEDs submitted during the previous 12 months. Applying
five different match criteria for institutional and non-institutional
claims (four for each type), the system detects potential duplicate
claims and selects these for extraction. See
paragraph 2.0, for a description of
the five match criteria.
1.6.2 Institutional
potential duplicates are identified by the application of the match
criteria at the claim level. Non-institutional potential duplicates
are identified at the line item level. This distinction is important
in understanding how institutional and non-institutional claims
are displayed within the claim sets. Refer to
Section 1.4,
for details regarding claim set composition.
1.6.3 The second extract is performed
following the processing of each payment record cycle, generally
on a daily basis. The system maintains a table of all claims selected
as potential duplicates during the first extract, and extracts adjustments
and cancellations associated with these potential duplicates during
the second extract. The system attaches the adjustments and cancellations
to the appropriate DCS sets where users can access them.
1.6.4 The DCS databases store claim
level data for both institutional and non-institutional claims.
Examples of claim level data are: Internal Control Number (ICN),
sponsor Social Security Number (SSN), Patient ID, diagnosis code,
and the date the TED was processed to completion (PTC).
1.6.5 The system also stores line
item data for non-institutional claims. Examples of line item detailed
data are: procedure code, place of service, type of service, care
begin and end dates.
1.6.6 Addendum A, contains a description of the
data elements in the DCS databases.
2.0
Criteria
Used To Select Potential Duplicate Claims
The DCS uses the criteria described
on the following pages to extract TED data and load the DCS databases.
Prior to the National Provider Identifier (NPI) implementation,
the DCS inspects up to 12 TED data fields in each claim record;
on or after the NPI implementation, 14 TED data fields in each claim
record. If the claims match on one of the criteria categories, it
extracts and groups these claims into sets. The criteria used by
the system identifies claims with a high probability of being actual
duplicates.
2.1 Match Criteria for Institutional
Claims Prior to the NPI Implementation
The following categories of
match criteria are used to identify and link two or more matched
institutional claims.
Figure 4.1.2-1, shows the specific TED data
field match criteria used to select potential institutional duplicate
claims.
Exact Match
|
All 12 fields match.
|
Near Match
|
Five fields match and the lesser
Billed Amount is within 10% of the larger Billed Amount.
|
Date Overlap
|
Three fields match and the
beginning date of care of one claim falls between the beginning
and ending dates of another.
|
Other
|
Four fields match.
|
Other Inst.
|
Three fields (Patient ID, National
Provider Identifier (NPI) - Type II, and Care Begin Date) OR
Four fields (Patient ID, Provider
ID, Provider Sub ID, and Care Begin Date)
|
Figure 4.1.2-1 Data
Field Match Criteria For Institutional Claims Prior To The NPI Implementation
Field Name
|
Other
|
Date Overlap
|
Near Match
|
Exact Match
|
|
PATIENT ID
|
X
|
X
|
X
|
X
|
PATIENT DOB
|
|
|
|
X
|
PROVIDER TAX ID
|
X
|
X
|
X
|
X
|
PROVIDER SUB ID
|
X
|
X
|
X
|
X
|
ADMIT DATE
|
|
|
|
X
|
BILL FREQUENCY
|
|
|
|
X
|
BILLED AMOUNT
|
|
|
± 10%**
|
X
|
ALLOWED AMOUNT
|
|
|
|
X
|
CARE BEGIN DATE
|
X
|
OVERLAP*
|
X
|
X
|
CARE END DATE
|
|
|
X
|
X
|
PRIN DIAGNOSIS
|
|
|
|
X
|
DRG CODE
|
|
|
|
X
|
2.2 Match
Criteria for Institutional Claims On or After the NPI Implementation
The following categories of
match criteria are used to identify and link two or more matched
institutional claims.
Figure 4.1.2-2, shows the specific TED data
field match criteria used to select potential institutional duplicate
claims.
Exact Match
|
All 14 fields match.
|
Near Match
|
Four fields match and the lesser
Billed Amount is within 10% of the larger Billed Amount.
|
Date Overlap
|
Two fields match and the beginning
date of care of one claim falls between the beginning and ending
dates of another.
|
Other
|
Three fields match.
|
Figure 4.1.2-2 Data
Field Match Criteria For Institutional Claims On Or After The NPI Implementation
Field Name
|
Other
|
Date Overlap
|
Near Match
|
Exact Match
|
|
PATIENT ID
|
X
|
X
|
X
|
X
|
PATIENT DOB
|
|
|
|
X
|
PROVIDER ID
|
|
|
|
X
|
PROVIDER SUB ID
|
|
|
|
X
|
NPI - TYPE II
|
X
|
X
|
X
|
X
|
ADMIT DATE
|
|
|
|
X
|
BILL FREQUENCY
|
|
|
|
X
|
BILLED AMOUNT
|
|
|
± 10%**
|
X
|
ALLOWED AMOUNT
|
|
|
|
X
|
CARE BEGIN DATE
|
X
|
OVERLAP*
|
X
|
X
|
CARE END DATE
|
|
|
X
|
X
|
PRIN DIAGNOSIS
|
|
|
|
X
|
DRG CODE
|
|
|
|
X
|
2.3
Match
Criteria for Non-Institutional Claims Prior to the NPI Implementation
The following categories of
match criteria are used to identify and link two or more matched
non-institutional claims.
Figure 4.1.2-3, shows the specific TED data
field match criteria used to select potential non-institutional duplicate
claims.
Exact Match
|
All 12 fields match.
|
Near Match
|
Six fields match and the lesser
Billed Amount is within 10% of the larger Billed Amount.
|
Current Procedural Terminology, 4th
Edition (CPT-4) Code Match
|
Five fields and the first three
characters of the procedure code match.
|
Other
|
Five fields match.
|
Figure 4.1.2-3 Data
Field Match Criteria For Non-Institutional Claims
Field Name
|
Other
|
CPT-4 Code
|
Near Match
|
Exact Match
|
|
Claim
Level
|
PATIENT ID
|
X
|
X
|
X
|
X
|
PATIENT DOB
|
|
|
|
X
|
PRIN DIAGNOSIS
|
|
|
|
X
|
Line Item
Level
|
PROVIDER TAX NBR
|
X
|
X
|
X
|
X
|
PROVIDER SUB ID
|
X
|
X
|
X
|
X
|
PLACE OF SERVICE
|
|
|
|
X
|
TYPE OF SERVICE
|
|
|
|
X
|
CARE BEGIN DATE
|
X
|
X
|
X
|
X
|
CARE END DATE
|
|
|
4
|
X
|
BILLED AMOUNT
|
|
X
|
± 10%**
|
X
|
ALLOWED AMOUNT
|
|
|
|
X
|
PROCED CODE
|
X
|
posn 1-3*
|
X
|
X
|
2.4 Match
Criteria for Non-Institutional Claims On or After the NPI Implementation
The following categories of
match criteria are used to identify and link two or more matched
non-institutional claims.
Figure 4.1.2-4, shows the specific TED data
field match criteria used to select potential non- institutional duplicate
claims.
Exact Match
|
All 14 fields match.
|
Near Match
|
Five fields match and the lesser
Billed Amount is within 10% of the larger Billed Amount.
|
CPT-4 Code Match
|
Four fields and the first three
characters of the procedure code match.
|
Other
|
Four fields match.
|
Other Inst
|
Four fields.
|
Figure 4.1.2-4 Data
Field Match Criteria For Non-Institutional Claims On Or After The
NPI Implementation
Field
Name
|
Other
|
Other
|
CPT-4
Code
|
CPT-4
Code
|
Near Match
|
Near Match
|
Exact
Match
|
|
Claim
Level
|
PATIENT ID
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
PATIENT DOB
|
|
|
|
|
|
|
X
|
PROVIDER ID
|
|
|
|
|
|
|
X
|
PROVIDER SUB ID
|
|
|
|
|
|
|
X
|
NPI - TYPE II
|
X
|
|
X
|
|
X
|
|
X
|
NPI - TYPE I
|
|
X
|
|
X
|
|
X
|
X
|
PRIN DIAGNOSIS
|
|
|
|
|
|
|
X
|
Line Item
Level
|
PLACE OF SERVICE
|
|
|
|
|
|
|
X
|
TYPE OF SERVICE
|
|
|
|
|
|
|
X
|
CARE BEGIN DATE
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
CARE END DATE
|
|
|
|
|
X
|
X
|
X
|
BILLED AMOUNT
|
|
|
4
|
4
|
± 10%**
|
± 10%**
|
X
|
ALLOWED AMOUNT
|
|
|
|
|
|
|
X
|
PROCED CODE
|
X
|
X
|
posn 1-3*
|
posn 1-3*
|
X
|
X
|
X
|
2.5 Exclusions
2.5.1 Exclusion of Certain Claims
The DCS excludes claims from
the extract if they do not meet specific minimum dollar thresholds
and other criteria. An individual claim is excluded if:
2.5.1.1 The Government paid amount
at the claim level is $0.00.
2.5.1.2 The total allowed amount is
less than $30.00.
2.5.1.3 The claim’s type of submission
code is B, D, E, or O (adjustment
or cancellation to a prior non-TED claim or 100% paid by other health
insurance).
2.5.1.4 The claim level allowed amount
on a non-financially underwritten institutional potential duplicate
is less than $30.00.
2.5.1.5 The claim level allowed amount
on an financially underwritten institutional potential duplicate
is less than $50.00.
2.5.1.6 The sum of the line item level
allowed amounts on a non-financially underwritten non-institutional potential
duplicate is less than $30.00.
2.5.1.7 The sum of the line item level
allowed amounts on an financially underwritten non-institutional potential
duplicate is less than $50.00.
2.5.1.8 The second byte of the claim’s
type of service code is B (Retail Drugs & Supplies)
or M (Mail Order Pharmacy Drugs & Supplies).
2.5.2 Exclusion of Certain Line Items
2.5.2.1 DCS excludes line items from
the extract if the line item procedure code (Healthcare Common Procedure
Coding System (HCPCS) or CPT-4) is one of the following:
HCPCS
|
CPT-4
|
Description
|
A4000 - A4999
|
06888
|
Nutrition Equipment/Supplies
- Purchase
|
A5000 - A6500
|
06942
|
Other Equipment/Supplies -
Purchase
|
R_ _ _ _
|
76499
|
Radiographic Procedure
|
P_ _ _ _
|
84999
|
Clinical Chemistry Test
|
P_ _ _ _
|
88305
|
Tissue Exam By Pathologist
|
|
90593
|
Whole Blood Charges
|
|
90594
|
Professional Components Charge
|
|
90595
|
Outpatient Hospital - Physician’s
Charge
|
|
90596
|
Outpatient Hospital - Recovery
Room Charge
|
|
90597
|
Outpatient Hospital - Operating
Room Charge
|
|
90599
|
Outpatient Hospital - Emergency
Room Charge
|
J_ _ _ _
|
90782
|
Injection (SC)/(IM)
|
J_ _ _ _
|
90784
|
Injection (IV)
|
|
94799
|
Unlisted Pulmonary Service
Or Procedures
|
|
99070
|
Special Supplies
|
|
99088
|
Other Room, Ancillary and Drug
Charges
|
|
99592
|
Hospital Outpatient Birthing
Room Charges
|
2.5.2.2 Anesthesia Assistants: When
comparing two line items which have the same CPT-4 value (all five positions),
if either of the CPT-4 Modifiers (CPT_4_1 or CPT_4_2) on one line
item has a value of QK and either of the CPT-4 Modifiers
on the other line item has a value of QX or a value
of QS.
2.5.2.3 Assistant Surgeon Modifiers:
When comparing two line items which have the same CPT-4 value (all five
positions), if either of the CPT-4 Modifiers on one of the line
items has a value of 80, 81, 82,
or AS and neither of the CPT-4 Modifiers on the other
line item has any of these values.
2.5.2.4 Left/Right: When comparing
two line items which have the same CPT-4 value (all five positions),
if either of the CPT-4 Modifiers on one of the line items has a
value of RT and either of the CPT-4 Modifiers on the other
line item has a value of LT.
2.5.2.5 Professional/Technical Components:
When comparing two line items which have the same CPT-4 value (all
five positions), if either of the CPT-4 Modifiers on one of the
line items has a value of 26 and either of the CPT-4
Modifiers on the other line item has a value of TC.
2.5.2.6 Ambulance Services: When comparing
two line items which have the same CPT-4 value (all five positions)
and that CPT-4 value is in the range of A0021 through A0999,
if the values of the first CPT-4 Modifier (CPT_4_1) on the two line
items are not equal.
2.5.3 Other
Exclusions
After
potential duplicate claims have been identified and grouped into
claim sets, a final test is applied to exclude certain types of
claim sets least likely to contain actual duplicate claims. Claim
sets are excluded if they meet any of the following conditions:
2.5.3.1 The claim set contains less
than two claims after the elimination of claims in the set due to
any of the previously listed exclusion criteria.
2.5.3.2 The set is a “Mother-Baby”
claim set and contains no more than two claims, where one claim
has a 6... series principal diagnosis code (mother
- O00-O9A) and the other claim has a V or Z... series
principal diagnosis code (baby - Z38...). (Applies
only to institutional claims.)
2.5.3.3 The set is a “Multiple
Birth” claim set and contains no more than two claims, where
both claims have V31... through V39... (International
Classification of Diseases, 9th Revision (ICD-9)) or Z38.1
through Z38.8 (International Classification of Diseases,
9th Revision (ICD-10)) series principal diagnosis codes. (Applies
only to institutional claims.)