Executive
Summary

Highmark and its subsidiaries including Xact Medicare Services (a Part B Carrier) have joined forces to develop a synopsis on the issue of health care claim attachments. Claim attachments affect the entire health care industry and we as a payer have dealt with a wide variety of attachments. We need to move toward the automation of attachments and have listed our comments on this issue which include perspectives on both Government and private insurer programs.

Highmark feels it is imperative that the Proof of Concept group continue on its current path of attachment standardization. Any disruption or delay at this point could cause major setbacks to the designation of the HIPAA standard for attachments.

Attachment Questions

1. What is your definition of a claim versus a claim attachment?

A claim is:

• a form submitted by a provider and/or sponsor/subscriber requesting payment or predetermination for services performed.
• is data about services performed, the provider of those services, subscriber/patient data, insurance information including other payer and previous payment by those payers.

A claim attachment is:

· documentation supporting rationale, justification or outcome of the services; such as, certifications, medical records and images.

In development of the current electronic standard, the direction has been to include certifications into the claim record. Long term, such information may be better placed and managed as a separate transaction. This would mean a separate certification transaction could still be submitted at the same time as the original claim. Bundling this data with the claim is not necessary for meeting a requirement for certain certifications to be submitted with the original claim.

2. How should we differentiate information that is appropriate for the claim versus information that is appropriate for claim attachments?

Data that can be submitted as part of the current claim form or record should be part of the claim.

Anything that cannot be submitted on the claim form should then be included as an attachment.

We need to come to a common definition of a claim and an attachment, see comments in (1) above. Supporting documentation should not be incorporated into the claim merely because that information is requested by some health plans with the original claim. X12 syntax supports submission of a claim and a separate supporting attachment with a direct electronic tie between the two.

3. What types of claims attachments do you currently request from providers? In what format do you make such request? In what format do you receive this information?

Please refer to Appendix 1

4. What other types of documentation do you currently request from providers? In what format do you make such requests? In what format do you receive this information?

For portable x-ray suppliers and ambulance suppliers on review, we require nurses notes, etc. from nursing facility or hospital. Our request for information would be sent to the nursing home or hospital facility.

We make these requests through automatically generated letters. Usually requests for other payer Explanation of Benefits (for coordination of benefits) is mailed to the sponsor/subscriber, while the remainder of the letter requests are to the provider submitting the claim.

5. What purpose(s) do these attachments and other documentation serve?

Many attachments are requested to provide evidence of medical necessity and/or level of care for the service(s). Some documentation is requested to verify whether the service was actually performed or clarify what service was performed.

The documents allow us to process the claim to completion.

Explanations of Benefits (EOBs), including Explanations of Medicare Benefits (EOMBs), allow us to correctly coordinate benefits among multiple insurance coverages. In some instances, Highmark is secondary and the primary insurer must first process, as evidenced by the EOB/EOMB.

Medical records, treatment plans, photos and Certificates of Medical Necessity (CMNs) all help us evaluate medically necessity and/or appropriate reimbursement for services rendered. Many times, these documents are forwarded to a contracted medical advisor for review.

6. What aspects of these processes would be aided by standardization and electronic exchange of information?

Using electronic exchange to inform providers of the information required, would improve our claims processing timeliness since all claimants would be required to provide the same documentation for a specific type of claim.

An increase in the number of attachment types that can be handled electronically will eliminate one of the reasons claims are submitted on paper instead of electronically. That is, it will increase electronic submissions, meaning administrative savings.

7. What aspects of these processes are not conducive to standardization?

Not all cases can be handled the same way. For providers whose practice we are closely scrutinizing, we need the option to flexibly request additional information based on specific carrier needs.

X-rays, periodontal charting & operative notes would be difficult to standardize because different insurers may have different policies on the requirement for these attachments.

8. What is the relationship between claims attachments and the medical record?

From a coverage or medical necessity review standpoint, the claim attachment is part of the medical record.

Medical records can be a claim attachment and are frequently acquired separately from the claim.

Claims sometimes come in with additional documentation; however, in most cases, this is requested from the provider (either before or after a claim is processed) and submitted separately.

9. Do you ever request the entire medical record from providers in support of the claim? Under what circumstances is the entire medical record required?

Generally, for pre-processing claim review, we only need information relating to the date of service in question. For post-processing utilization review and, perhaps, fraud investigation, it may be necessary to request records for an entire hospital stay or specific time period a patient resided in a nursing home.

We request the entire medical record for situations relating to concurrent care, serial surgery, cosmetic surgery, team surgery, and specialized durable medical equipment.

10. Currently, the NUCC and NUBC have the responsibility for approving the content of information contained in the standard health care claim. Do you think such an organization should also have responsibility for approving the content of claims attachments? Can you suggest which organization(s) should have this responsibility?

The same organization should have the responsibility for approving content of claims attachments as has the responsibility for approving content of information contained in the standard health care claim.

One concern we have identified with the NUCC and NUBC is past discussions with members have indicated some sentiment for a move to eliminate attachments and require health plans to process claims based solely on claim information. Payers must have an effective voice to ensure that we receive the data required so that contract provisions and business interests can be administered.

11. If there was a governing body over data content of the standard attachment data, there would have to be a protocol in place to add, delete, modify, etc. existing data content of the attachment. What are your suggestions/concerns regarding this process?

We would recommend that the governing body solicit comments from all payers and health plans and provide notice before implementing any changes.

If the NUCC and NUBC are endorsed as the managing bodies for attachments, there should be reassessment of their operating rules, a clarification of their mission and a look at participants and make-up of the groups. Clearly, all the players in the health care arena must be a part in these decisions.

General Comments

One issue to consider for expanding electronic attachments concerns the equipment needed to receive images at the payer site. At this time, this equipment typically is very expensive, and vendors’ resources are limited. Advanced technology machines would be required to view the detail of the requested images.