What is your definition of a claim versus an attachment?
The NUCC would define a claim as the submission of information by a provider or covered person, to establish that health care services were provided. The submission may be made either electronically or on paper, to a third-party payer. The claim includes a request for payment or reimbursement to the provider or covered person.
An attachment would be other information that may be included by the provider at the time of the claim submission to provide further supporting details, or additional information that is requested by the payer prior to the claim being adjudicated.
How should we differentiate information that is appropriate for the claim versus information that is appropriate for claims attachments?
The NUCC believes that a non-institutional health care claim and equivalent encounter information should be based on a uniform minimum/maximum data set. The data set should be equivalent across all products, contracts, and government programs (e.g., fee-for-service, managed care fee-for-service, managed care capitation, etc.). The data set should also include a limited set of additional data elements intended to serve as “replacements for attachments” (e.g., additional information to specify any extenuating circumstances or justifications that may assist the payer in the review). In addition, the data set should standardize optional or statutorily required elements.
The NUCC further believes that the number of attachments required should be reduced, the process for handling the attachments should be improved, and the data required on an attachment should be clarified.
In addition, the NUCC believes that the non-institutional uniform data set and associated attachments requirements should constitute the data required by any public or private payer to process a claim.
What types of claims attachments are requested from providers? In what format are the requests made? In what format is this information received?
Payer representatives to the NUCC have stated that they ask for a variety of information in order to adjudicate a claim. Some of this information can be found on the patient’s medical record, such as operative notes, test results, reports, etc. Government payers also request information using standard forms to reflect patient consent, medical necessity of durable medical equipment, duration of drugs, etc.
Some of the requests require administrative/billing and clinical content such as ambulance claims, outpatient rehabilitation, emergency room reports and records, referrals, explanation of benefits, etc. Also, payers look for information on supplies such as drugs and duration or supplies and their price.
Payers also request information about contradictions on the claim, such as seemingly incorrect coding and information to substantiate claims, such as certification documents and assignment of benefits information.
The method of requesting and receiving this information depends upon the relationship a payer has with the provider and their technological capabilities. Some providers are able to receive and respond to these requests electronically. Payers also request and receive information from providers via the mail, fax, and telephone systems.
What purpose(s) do these attachments and other documentation serve?
From the NUCC perspective, attachments serve many purposes. Payers may request additional information to determine medical necessity. Some attachments are required for contractual agreements or government mandates. Attachments are sometimes used for internal audits, such as pre- and post-adjudication review. Requests for information may also be made because of a dollar threshold on a patient’s plan. Additional information may often be requested if there are concerns regarding possibly fraudulent claims. Information may also be collected in order to help with state rate settings and to determine cost-benefit analyses. Payers may also request attachments to manage changes in care patterns as a result from the additional data.
Regardless of whether claims are received on paper or electronically, many must be reviewed manually. According to a 1996 report of a survey conducted by the Health Insurance Association of America, 18% of claims are “pended” for one of several reasons, including coordination of benefits, “cost containment purposes”, or other reasons. They may also be pended for inadequate data on the claim form, which may initiate the request for attachments. The data suggests that, in addition to standardizing the transaction protocol and claim forms, the minimum/maximum data requirements must apply to all payers and providers and cover both paper and electronic transactions.
What aspects of these processes would be aided by standardization and electronic exchange of information?
The NUCC believes that standardization and electronic exchange of attachment information could reduce the workload for all of the key parties affected by health care electronic data interchange - those at either end of the health care transaction – generally payers and providers.
It is essential, however, that, the types of requests for information, the expected content, and the format be standardized. This means that the types of requests and the corresponding data elements need to be defined and then these parameters should constitute the data required by any public or private payer to process a claim.
What aspects of these processes are not conducive to standardization?
The members of the NUCC have indicated that there are many proprietary systems for attachments in use today. There are also many mandates by public payers both at the state and federal level that may be difficult to standardize. Standardization could be even more difficult in the private sector, where contractual provisions vary across and within specific companies.
Some NUCC members have acknowledged that another aspect inhibiting standardization is the fact that providers are at various levels of electronic capability, and that it may be too cost-prohibitive for many of them to purchase new equipment in order to handle the requests for attachments in a standardized format.
Given the fact that providers are using thousands of different versions of clinical and administrative software systems, and that the percentage of electronic medical systems remains very low, the standardization of claims attachment information should be limited to a well defined set of possible attachments.
Automation of clinical data will occur at different rates throughout the health care industry. Larger health care delivery systems such as hospitals, integrated health networks, and managed care settings will continue to lead the trend in automation. This trend will occur slower in the ambulatory setting with the larger practices automating first. All these factors must be considered when defining the requirements and developing standards.
Therefore, in order for administrative simplification to be realized, the claims transactions must consist of uniform data content; the claims data sets should include a limited set of additional data elements intended to serve as replacements for some attachments; the data requirements outside of the claim need to be limited to a defined number; and the payers must standardize their processing methods.
What is the relationship between claims attachments and the medical record?
The NUCC believes that claims attachments, as specified in HIPAA, are not synonymous with the patient medical record or detailed clinical information, though some attachment information may be derived from a patient’s medical record. The NUCC is fully supportive of ongoing efforts to develop standards for computer-based patient records. However, the NUCC believes this is an issue that is most appropriately viewed as largely separate from the insurance transactions currently being considered and beyond the specific mandates of HIPAA administrative simplification.
Is the entire medical record ever requested from providers in support of the claim? Under what circumstances is the entire medical record required?
The NUCC payer representatives have stated that they may require the entire record in certain circumstances if the entire record is necessary to adjudicate the claim. However, the provider may send the entire record along with the claim without such requests in order to expedite the payment of the claim.
If the entire record is requested, only the information necessary to adjudicate the claim should be extracted and confidentiality safeguards must be assured.
Currently, the NUCC and the 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 the responsibility for approving the content of claims attachments? Can you suggest which organization(s) should have this responsibility?
The NUCC believes that there should be an organization, other than those entities currently responsible for the development of the messaging transactions, responsible for managing the content of claims attachment transactions. As a general principle, the development and maintenance of the content and the messaging architecture are two distinct roles and although the functions must be coordinated, they should remain independent of each other.
It is logical that the organizations responsible for claims data content (and similar HIPAA transactions) are also responsible for the claims attachment content. These organizations should be formally representative of all parties affected by health care electronic data interchange (e.g., providers, payers, standards development organizations, and regulatory agencies). Based on their structure and current and anticipated responsibilities, the NUCC and the NUBC are fully appropriate to assume this responsibility.
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?
The NUCC has an official operating protocol that addresses modifications to claims data content. This protocol provides full due process, open meetings, and the ability of non-members to generate agenda items. It is being revised to broaden the parties represented on the NUCC and to address the need for additional appeals processes.
Fundamentally, data content should be maintained through committees, like the NUCC and the NUBC, that focus on formal representation of key parties to the transactions for which they are responsible, using a consensus approach to decision-making. Data content maintenance is a quasi-policy activity that should be conducted through the kind of public/private partnership that these two committees exemplify and not viewed as a primarily technical communications standard.
The NUCC recently coordinated a meeting with all of the content committees pertinent to the HIPAA transactions (i.e., NUCC, NUBC, ADA, and NCPDP) to discuss future coordination activities. Although some individual committee members participate on more than one committee, it was agreed that data sets must be coordinated and that the committees must work closely to this end.