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TRICARE Operations Manual 6010.59-M, April 1, 2015
Claims Processing Procedures
Chapter 8
Section 9
Duplicate Payment Prevention
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.  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.  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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