The Department issued Medical Assistance (MA) Bulletin 99-08-17 on October 20, 2008. The bulletin contains specific examples to explain how ClaimCheck® edits impact claims processing. The bulletin also identifies the different entities and sources that provide the clinical rationale to support ClaimCheck® edits. Any services covered by the MA Program Fee Schedule can potentially be impacted however an attachment to the bulletin, Attachment A - ClaimCheck® Claims Criteria, identifies the specific types of claims and services that are included and excluded from editing requirements.

Services provided by outpatient rehabilitation facilities will be subject to ClaimCheck® audits unless the types of services being rendered are excluded from editing requirements. For example, if services are related to behavioral health, then the claim will be excluded from ClaimCheck® editing. Please refer to Medical Assistance (MA) Bulletin 99-08-17, Attachment A – ClaimCheck® Claims Criteria, for a list of exclusions.

It is difficult to say what percentage of billing errors will be detected by ClaimCheck®. The percentage can vary nd will be impacted by factors such as the procedure code/s and procedure code combinations billed on a current claim or history claim, the accuracy of the information reported and whether or not the reported information is consistent with nationally recognized clinical guidelines, industry standards, and coding guidelines.

MA will continue to pay at the service line item level. Error Status Code (ESC) messages will be returned and displayed on a Remittance Advice (RA) with a description.

The department's website was updated to display all of the new ClaimCheck Error Status Codes (ESC) numbers along with the short description and long description. The ESC ranges are 3500 through 3599, 3602 through 3606, and 9018.

Error Status Codes and Descriptions

Click on one of the PDF documents below to get more detailed information about Error Status codes (ESC) an what they mean. Error Status Codes appear on Remittance Advices are returned on interactive claims to indicate the disposition of claim(s) submitted to PROMISe™ for processing.