14_TCRS_Sec_J_Atch_J-4_Smpl_Final_Rdns_Test_Rpt.pdf

Attachment J-4 Sample Final Readiness Test Report

TCRS HT9402-17-R-0002, Section J, Attachment J-4 Page 1 of 3

Department of Defense – Defense Health Agency

Comprehensive Readiness Test January 23 – February 01, 20XX

Final Report Summary

TCRS HT9402-17-R-0002, Section J, Attachment J-4 Page 2 of 3

COMPREHENSIVE READINESS TEST

(CONTRACTOR NAME)

TRICARE CLAIMS REVIEW SERVICES

FINAL REPORT SUMMARY

A response to the Initial Readiness Test Report was received from (contractor name) dated (mm/dd/yyyy). (contractor name) provided a response to each of the 7 failed test scenarios in their response, in which they were in agreement with two of the “fails” assessed, and disagreed with 5 of the “fails” assessed.

Of the 200 test claims, seven (3.5%) were reviewed incorrectly and 193 (96.5%) were reviewed correctly. The details and final determinations regarding the specific errors for each of the 7 test scenarios in question are addressed in the enclosed Failed Claims Report.

Following is a final summary listing of each error category and the associated number of claims in error:

ERROR CATEGORY

NUMBER OF CLAIMS IN

ERROR

Benefit Determination Errors 2 Copay/Cost share Errors 2 Non-Covered Charges 1 Pricing Error 2

There were no significant trends or major issues identified during the readiness test, therefore, the overall claims review performance is acceptable. Any future issues will be addressed by the TCRS Contracting Officer’s Representative.

Attachment:

Failed Claims Report

TCRS HT9402-17-R-0002, Section J, Attachment J-4 Page 3 of 3

TCRS READINESS TEST

FAILED CLAIMS REPORT

Test Scenario # : 026 (1) Error Category: Benefit Determination Readiness Team Comments: Charge for CPT 45300, as a preventive procedure, should have been denied, as the patient is outside the allowable age range. Also, CPT 80061 was correctly allowed, but a cost-share should have been applied.

Contractor Comments:

Test Scenario # : 038 (2) Error Category: Benefit Determination Readiness Team Comments: Charges for CPT 82270 and CPT 81000 should have been denied as not medically necessary.

Contractor Comments:

Test Scenario # : 174 (3) Error Category: Cost-Share Error Readiness Team Comments: Charges submitted are for services rendered with a medically necessary diagnosis, and should not have preventive cost-shares applied.

Contractor Comments:

Test Scenario # : 195 (4) Error Category: Cost-Share Error Readiness Team Comments: Charges submitted are for services rendered with a medically necessary diagnosis, and should not have preventive cost-shares applied.

Contractor Comments: