Here’s what you need to know about medical record reviews

There are many reasons a health care provider may receive a request for a medical records review — including ensuring that a member is receiving quality care (see article on HEDIS medical record reviews in this issue), following up on a member appeal and investigating possible fraud or abuse. Whatever the reason, our research has shown that submitting medical records is one of the major “pain points” for providers. With that thought in mind, we’d like to provide some guidelines that we hope will ease the process for providers:

General guidelines

• Take the time to carefully read the request you receive and understand exactly what’s being requested. If you’re unsure, call the number provided. Otherwise, you risk sending the wrong information, delaying the process.
• When submitting a medical record for review, include the patient’s date of birth on the record or a demographic sheet containing the patient’s address, contract number, date of birth and other key information.
• If including handwritten notes, make sure the documentation is legible.
• If you’ve submitted a medical record for review and haven’t heard back, don’t assume something is wrong and send additional, unsolicited information. You can call the number on the request to obtain a status update.

Closing gaps in care
One of the main reasons Blue Cross Blue Shield of Michigan may request a medical record review is to ensure that providers are closing gaps in care as part of an effort to boost HEDIS^® scores.** HEDIS initiatives address issues such as ensuring that members receive necessary preventive health screenings and effectively managing a member’s chronic condition. To reduce the need for medical record reviews related to closing gaps in care, be sure to:

• Submit claims with CPT Category II codes to help us determine if specific HEDIS measures are met without needing to request and review medical records.
• Use appropriate ICD-10 codes if you need to indicate that a member is excluded from a specific measure.

BlueCard^® claims
When submitting medical record requests regarding BlueCard claims, keep the following in mind:

• The home plan may have different medical criteria than Blue Cross Blue Shield of Michigan. It’s important to use the Medical Policy and Pre-Cert/Pre-Auth Router, available from the BCBSM Provider Publications and Resources page of web-DENIS, to determine the policy and authorization needs of out-of-state Blue Cross plans.
• When a home plan needs to conduct a medical record review, a medical records request is sent. Don’t submit medical records unless you’ve received a medical record request letter.
• If your claim has been rejected citing a need for medical records and you have not received a medical request letter, contact Provider Inquiry for assistance.
• Unsolicited medical records submitted to Blue Cross Blue Shield of Michigan aren’t forwarded to the member’s home plan.
• Only send the items requested in the medical record request.
• If you’re unsure of what’s needed, contact Provider Inquiry for assistance.
• If you’re unable to provide what’s being requested, respond to the request and indicate the reason you’re unable to provide the requested information.
• The member may need to help obtain the information.
• Allow 30 days for review of medical records.

For more information

• Review your online provider manual for medical record documentation guidelines.
• If you have a question about a specific situation that isn’t addressed in this article, contact Provider Inquiry.
• Check out our Clinical Quality Corner tip sheets on web-DENIS for additional details on proper coding and documentation for specific HEDIS measures. You can access them from the BCBSM Newsletters and Resources page of web-DENIS.

Note: We’re currently updating our tip sheets for 2019 and will share them with you as soon as available.

**HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance, or NCQA.