We’re enhancing our claims processing systems to link medical records and claims

Blue Cross Blue Shield of Michigan and Medicare Advantage are enhancing their claims processing systems to better support instances where we require medical records in order to finalize a professional or institutional claim service. We expect that we’ll be able to systematically link a medical record to its corresponding claim before the end of 2016. Note: Blue Care Network, FEP and BlueCard^® claims are excluded from these changes. However, FEP will participate in the use of the Medical Record Routing Form.

Medical records are the supporting clinical documentation (e.g., patient history, lab results and medical reports) that cannot be sent as part of or within the electronic claim (the 837 transaction).

Implementation of this linkage capability will require the following:

• When Blue Cross or Medicare Advantage requires additional documentation (medical records) to finalize a claim service, the electronic claim must indicate that medical records are being sent (the PWK segment of the 837). If the electronic claim doesn’t indicate additional documentation is being sent, the service will automatically reject.
• When Blue Cross or Medicare Advantage requires additional documentation (medical records) to finalize a claim — and you have indicated on the 837 that the information is being sent — it must be received within seven days of the electronic claim receipt. If the medical records aren’t received within seven days, the service requiring documentation will be rejected.
• We’ll be expanding the current use of the Medical Record Routing Form to allow for the submission of medical records related to an original electronic claim for Blue Cross Blue Shield of Michigan, Medicare Advantage and FEP members. The form will be updated to include the new information required for these types of claims.

We’ll include additional information about this new capability in future issues of The Record.