How insurance identifying duplicate claim - process involved .

Detection of Duplicate Claims

The claims processing systems contain edits which identify exact duplicate claims and suspect duplicate claims. All exact duplicate claims or claim lines are auto-denied or rejected (absent appropriate modifiers). Suspect duplicate claims and claim lines are suspended and reviewed by the claims administration contractors to make a determination to pay or deny the claim or claim line.

Some claims that appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances of an item or service, for which Medicare payment may be made. Correct coding rules applicable to all billers of health care claims encourage the appropriate use of condition codes or modifiers to identify claims that may appear to be duplicates, but, in fact, are not.

For example, there are some HCPCS modifiers that are appropriate to be appended to some services and can indicate that a claim line is not a duplicate of a previous line on the claim. Level I modifiers would typically be used by a biller to indicate that a potential duplicate claim or claim line is not, in fact, a duplicate. Level II modifiers may also be used. The Level II modifiers “RT” and “LT”, for example, indicate that a service was performed on the right and left side of the body, respectively.

However, not every HCPCS code has an associated modifier to indicate that a claim line is not a duplicate. In that case, the claims and claim lines are reviewed by Medicare contactors’ local software modules for a determination or they suspend for contractor review.

 Exact Duplicates

Exact duplicates are controlled by the claims processing system through “hard coded” edits, and may not be user-controlled. In addition, Medicare contractors cannot override or bypass exact duplicate edits.

A. Submission of Institutional Claims

Claims or claim lines that have been determined to be an exact duplicate are rejected and do not have appeal rights. An exact duplicate for institutional claims is a claim or claim line that exactly matches another claim or claim line with respect to the following elements:

• HIC number;

• Type of Bill;

• Provider Identification Number;

• From Date of Service;

• Through Date of Service;

• Total Charges (on the line or on the bill); and

• HCPCS, CPT-4, or Procedure Code modifiers.

Additional Instructions for Institutional Claims:

Whenever any of the following claim situations occur, the MAC develops procedures to prevent duplicate payment of claims. This includes, but is not limited to:

• Outpatient payment is claimed where the date of service is totally within inpatient dates of service at the same or another provider. Do not consider outpatient services provided on the day of discharge within the inpatient dates of service.

• Outpatient bill is submitted for services on the day of an inpatient admission or the day before the day of admission to the same hospital.

• Outpatient bill overlaps an inpatient admission period.

• Outpatient bill for services matches another outpatient bill with a service date for the same revenue code at the same provider or under a different provider number.

1. History File - Paid Claims

The MACs and legacy claims administration contractors must maintain a history file containing information about each claim processed. The file may consist of the claim or information from it. It must contain the following minimum information:

o Beneficiary HICN;

o Beneficiary name information;

o Provider identification (name or number); and

o Billing period from the claim.

Claims or claims information in the history file may be transferred to inactive files. However, the MAC must have the facility to recall such claims or information if a claim for the beneficiary involving the same time period is received.

2. History File - Pending Claims

Contractors must have controls to prevent a duplicate claim from being paid while two claims are in the process within the system at the same time. This may be accomplished through a special check of in-process claims or in the history file for paid claims. The file should contain the same minimum information indicated in the subsections below. The check should be performed prior to sending the claim to CWF.

3. Analysis of Patterns of Duplicate Claims

The contractors shall establish a system for continuing analysis of duplicate claims. This includes the systematic evaluation of returned “Medicare Summary Notices” from beneficiaries and communications from providers indicating a duplicate payment has been made, as well as returned checks from any payee.

The contractor’s system should provide for analyzing duplicate claim receipts to determine whether certain providers are responsible for duplicates and, if so, identify those providers. The contractor should educate such providers to reduce the number of duplicates they submit. Should those providers continue to submit duplicate claims, the MAC should initiate program integrity action.

B. Claims Submitted by Physicians, Practitioners, and other Suppliers 

Claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. However, such denials may be appealed. An exact duplicate for physician and other supplier claims submitted to a MAC or carrier is a claim or claim line that exactly matches another claim or claim line with respect to the following elements:

• HIC Number;

• Provider Number;

• From Date of Service;

• Through Date of Service;

• Type of Service;

• Procedure Code;

• Place of Service; and

• Billed Amount.

C. Claims Submitted by DMEPOS Suppliers

Claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. Such denials may not be appealed. An exact duplicate for DMEPOS supplier claims submitted to a DME MAC is a claim or claim line that exactly matches another claim or claim line with respect to the following elements:

• HIC Number

• Through Date of Service;

• Place of service;

• HCPCS code;

• Type of Service;

• Billed Amount;

• Supplier

D. Claims Submitted by Multiple DMEPOS Suppliers

When a second DMEPOS supplier or multiple DMEPOS suppliers submit a claim during a span date already approved for the same beneficiary for a different DMEPOS supplier, the DME MAC shall deny the second or subsequent DMEPOS supplier’s claim as a duplicate not a suspect duplicate when the following conditions are met:

• Same Beneficiary Health Insurance Claim Number (HICN)

• Overlapping span Date of Service (DOS) (From DOS and Through DOS)

• Same Healthcare Common Procedure Coding System (HCPCS) Code,

• Same Type of Service on the incoming claim matches a previously approved claim in history, and

• The item is a diabetic testing supply

• Items Subject to Duplicate Editing

1. Diabetic Testing Supplies

 Suspect Duplicates

Suspect duplicates are claims or claim lines that contain closely-aligned elements sufficient to suggest that duplication may be present and, as such, require that the suspect claim be reviewed. Suspect duplicate edits can be hard coded in the system or local edits set up by Medicare contractors.

A. Criteria for Detecting Suspect Duplicates for Institutional Claims

A “suspect duplicate” claim is a claim being processed which, when compared to the history or pending file, begins with these characteristics:

• Match on the beneficiary information;

• Match on provider identification, and

• Same date of service or overlapping dates of service.

The contractors examine and compare to the prior bill any bill that is identified as a suspect duplicate. If the services (revenue or HCPCS codes) on a claim duplicate the services for the other, contractors should check the diagnosis. If the diagnosis codes are duplicates, obtain an explanation from the provider before making payment.

B. Suspect Duplicate Claims Submitted by Physicians and other Suppliers (including DMEPOS Claims)

The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers are not published and vary according to the type of billing entity, type of item or service being billed, and other relevant criteria. The denial of claim as a duplicate of another claim may be appealed when the denial is based on criteria other than those specified above for exact duplication.

A/B MACs, Part B legacy contractors, and DME MACs must add an informational indicator to the Common Working File (CWF) transaction record when, as a result of a contractor audit/edit or CWF reject, the contractor examines what appears to be a duplicate item or service and approves it for payment.

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