|
Report Description:
|
This report shows line items
which appear on non-institutional claims which carry
a CPT-4 match type (C) at the claim level (see REPORT
NOTES below). Due to the way the Duplicate Claims System assigns
match types to claims and sets, this report must be used very carefully.
Users have the option in this report of selecting actual duplicate
claims only. The user may think that the report is showing only
actual duplicate line items identified by the CPT-4 match type criteria.
In fact, the report is showing the line-items of actual (Y)
non-institutional duplicate claims which have been assigned a match
type of CPT-4 (see REPORT NOTES below). As a result, line items
identified using the OTHER match type may appear on this report
along with the line items identified under the CPT-4 criteria which
caused the claim to be assigned the match type of CPT-4. This report
will not show any line items identified under the EXACT or NEAR
match criteria since line items identified using the EXACT and NEAR
match would force the claim(s) to be assigned a higher level match
type than CPT- 4. This report looks for only those actual duplicate
non-institutional claims with a match type of CPT-
4 and then lists the line items on those claims.
This report can be used by
Program Integrity staff to obtain a listing of the claims carrying
a match type of CPT-4 and their associated line items. Using the
Provider Claim Count Report, users can identify the provider numbers
associated with high volumes of non-institutional claims involving
line items whose last two digits of the procedure code have been
changed. Then using the Provider CPT-4 Report and entering those
provider numbers identified, the user can generate a listing of
the non- institutional claims with line item details associated
with those provider numbers.
The fields displayed on this
report are: ICN; Time Stamp; Claim Level User Defined Code; Solicited
Indicator; Set #; Duplicate Flag Indicator; Sponsor ID; Patient
ID; Patient Name; Line Item Match Type; Line Item Number; CPT-4
Code; Amount Paid CPT-4; PTC Date; and Responsible FI. The report
is grouped by Provider Number and Sub-ID and provides sub-totals
for each provider Sub-ID and grand totals for each provider Tax-ID.
The sub-totals and grand totals sum the number of line items and
the total Paid dollars.
Users may customize the report
by selecting: All “Standard” parameters minus Match Type, Claim
Type, Last Dates, Set Range (Set Owner Type, Claim Set Status, Adjustments,
Date Type, FI, Region) plus Dupe Flag Indicator, Solicited Indicator, PTC
Dates, Responsible FI, Region, Set Level User Defined Codes, Claim
Level User Defined Codes, and Provider Tax ID.
|
|
Report Parameter Options:
|
Users may customize the report
by selecting: All claims or actual duplicate claims only (to be
counted as an actual duplicate claim, it must have a Y dupe
flag and be in a Pending, Validate,
or Closed set); status (All, Open, Pending, Closed, Validate); only
sets that have adjustments associated with them; multi-FI sets,
single FI sets, or both; set match type (All, Exact,
Near, Date Overlap, CPT-4, Other); a single processed-to-completion
date or a range of processed-to- completion dates; a single load
date or a range of load dates; one or all FIs; one, several or all
regions within selected FIs. Users may also select one, several
or all Provider Tax ID numbers to be included in the report.
|
|
Report Notes:
|
Match types are applied at
the line-item, claim, and set levels based on a hierarchy. The most
stringent match type applicable is assigned at each level. The hierarchy
for institutional claims is as follows: Exact, Near, Date Overlap
and Other. For non-institutional claims, the hierarchy is as follows:
Exact, Near, CPT-4, and Other. For both claim types, Exact Match
criteria is the most stringent with Near Match next. Other Match
is the least stringent. When the Duplicate Claims System identifies
non-institutional potential duplicates, it is doing so at a line
item level. When a line item is identified as a potential
duplicate, the system labels the line item with the
Match Type used to identify it as a potential duplicate. If a non-institutional claim contains
line items identified as potential duplicates using more than one
match type criteria (one line item identified under Exact Match criteria
and another line item under CPT-4 criteria), the system uses the
match type hierarchy and labels the claim with the
most stringent match type appearing on the line items. If the set contains claims labeled
with different match types (one claim labeled ‘Near’ and another
labeled ‘CPT-4’), the system uses the match type hierarchy and labels
the set with the most stringent match type appearing
on the claims.
|