Claim attachment enhancement coming in August

As we wrote in the December 2015 Record, Blue Cross Blue Shield of Michigan will be enhancing its claims processing systems to systematically link faxed or mailed additional documentation to a corresponding professional or institutional electronic claim.

This enhancement, effective Aug. 5, will allow us to process your claim, along with the documentation, more quickly. It will also help us prepare for the anticipated electronic claim attachment federal mandate.

Blue Care Network, Federal Employee Program^®, Medicare Advantage and BlueCard^® claims are excluded from these changes. However, FEP will participate in the use of the Medical Record Routing Form.

What’s a claim attachment?
A claim attachment is additional documentation (e.g., medical records) that Blue Cross requires when there's a need to determine if the service reported is a covered benefit. Although the required additional documentation can't be sent as part of or within an electronic claim (the 837 transaction), Blue Cross can accept the documentation by fax or mail.

Blue Cross requires additional documentation for the following:

• Individual consideration procedure codes. Examples include surgical notes or detailed descriptions.
• Not-otherwise-classified procedure codes. Provide additional documentation when the procedure code description data element (Loop 2400 SV101-7/SV202-7) of the electronic claim only provides a partial explanation of procedure performed.
• Procedure code with modifier 22. Requires documentation to describe increased procedural services when the work performed is substantially greater than typically required.
• Procedure code with modifier 62. Requires documentation to describe when two surgeons work together as primary surgeons performing distinct parts of a procedure.
• Procedure code with modifier 66. Requires documentation to describe the collaboration of more than two surgeons for team surgery (surgical report).
• Air ambulance. Includes procedure codes A0424, A0430, A0431, A0435 and A0436; requires the ambulance run report and medical records that support the need for air transport versus ground transport.
• Hearing claims with modifier SC: Medically necessary service or supply requires support documentation regarding the service provided.
• Cosmetic service claims: Some procedures may be considered either cosmetic or reconstructive based on the indications for surgery; additional documentation is required to support the statement of medical necessity that justifies the surgery as reconstructive.

To ensure your additional documentation is linked to your claim:

• The electronic claim (837 transaction) should indicate that medical records are being sent. This is accomplished through the use of the PWK segment, or paperwork segment. If the electronic claim doesn’t indicate that additional documentation is being sent, the service will automatically be rejected.
• The documentation must be received within seven days of the electronic claim receipt. If the medical records aren't received within seven days, the service will be rejected.
• The updated Medical Record Routing Form must be used as the cover sheet for the additional documentation being faxed or mailed to us. The updated form includes the required information needed to link the additional documentation with your electronic claim in our system. The revised form will also continue to be used when submitting medical records to request review of a previously paid or denied claim. Following is an example of a completed original electronic claim form:

• Be sure to type in the required information on the form and print it so that claim attachments are linked to your claim. The information shouldn't be handwritten. Also, a paper claim should never be included with the form and documentation. When using the form to submit additional information required for a claim, choose the option on the form that states that the documentation is for an original electronic claim. The claim information provided on the Medical Record Routing Form must match the information you sent in the original electronic claim. Including:
• Patient information — the patient’s first name, subscriber’s last name and contract number. The number must begin with a three-digit alpha prefix or be an FEP contract number (R with eight digits).
• Date of service — If the service date includes a range of dates, use the first date of service.
• Billing NPI — This is the 10-digit national provider identifier of the health care provider that’s doing the billing.
• Patient control number — Either the patient account number or the claim number assigned by the billing submitter’s practice management system (maximum length of 20 characters). This should be provided, if available, but isn’t required.
• Attachment control number — This is the billing submitter’s unique document identification number; it should be different than the patient control number (maximum length of 50 characters). This should be provided, if available, but isn’t required.

Information regarding this enhancement will be shared at the upcoming provider informational forums. For more information on the forums, see the following two articles, also in this issue.

• Reminder: Provider informational forums coming to a city near you
• Reminder: Provider informational forums set for Upper Peninsula

Once the enhancement occurs, an online provider training resource will be added to web-DENIS. We’ll also include more information about this new capability in a future issue of The Record, and the online provider manuals will be updated to include a list of services that always require additional information.