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.
- END -