Claim Editing Policies & Procedures

Overview

ClaimCheck^® is an automated code auditing tool developed by McKesson that CIGNA uses for all medical products (i.e., HMO, PPO, OAP and Indemnity) to help expedite and improve the accuracy of processing professional claims. ClaimCheck logic is created following McKesson physicians' thorough clinical review of current clinical practice, specialty society expertise, and industry standard coding.

CIGNA will update ClaimCheck 8.5 to Knowledge Base Version 44 and National Correct Coding Initiative (NCCI) Version 15.3 Column 1/Column 2 (Incidental) and Mutually Exclusive code edits on February 15, 2010. CIGNA plans to update ClaimCheck to Knowledge Base Version 45 and NCCI Version 16.0 Incidental and Mutually Exclusive code edits on May 17, 2010.

With ClaimCheck 8.5, CIGNA applies the software's rules-based logic to:

• Assess Health Care Professional claims information, including Current Procedural Terminology (CPT^®) and Health Care Common Procedure Coding System (HCPCS) service codes to detect coding irregularities, conflicts or errors;
• Recommend CPT/HCPCS procedure code combinations and, when necessary, stop claims processing to obtain additional documentation;
• Implement CIGNA's coding guidelines, Coverage Policies, and Reimbursement Policies; and
• Put into practice the Centers for Medicare and Medicaid Services (CMS) coding and modifier guidelines and the National Correct Coding Initiative (NCCI) Incidental and Mutually Exclusive edits.

If you are not currently registered for the CIGNA for Health Care Professionals website you can complete the registration process and log on. Go to www.cignaforhcp.com and click on the Register link located under Personalized Self-Service Websites.

For additional information, call the Customer Service Center at 1.800.88CIGNA (882.4462).

Viewing CIGNA Claim Coding Edits

Viewing claim code edits can be made easier with Clear Claim Connection. This disclosure tool, allows you to enter CPT and HCPCS codes and immediately view the audit results. Edit Clarifications present the rationale behind a ClaimCheck edit or the definitions of NCCI edits.

Clear Claim Connection is accessible through the secure CIGNA for Health Care Professionals website at www.cignaforhcp.com. Once logged on, you may review the Clear Claim Connection Frequently Asked Questions for more information.

CIGNA is committed to providing solutions that can minimize your administrative costs while helping to reduce the complexity of doing business with us.

ClaimCheck Frequently Asked Questions (PDF 70k)