Thursday, November 24, 2016

Insurance requests for medical records - Retrospective review

1. Insurance  staff members conduct medical review of claims and seek the advice of qualified and, typically, practicing professionals when necessary. Contracting providers agree to accept the decisions made as a result of those reviews and to follow the appeals procedures established by this Policy Memo.

2. The entire review process itself includes the development of guidelines that relate to specific provisions of members' contracts; the processing of claims based on guidelines and medical records when indicated; the retrospective review of claim determinations; and the appeal process. Insurance  seeks the advice of clinical professionals at appropriate points throughout the entire review process.

3. Contracting providers must submit all pertinent and complete medical records to Insurance  within the time frame specified by Insurance  when records are needed for the initial review of a claim or when records are requested for an audit. In most instances, Insurance  will allow 30 calendar days for the production of the requested records. In certain unusual circumstances as determined solely by Insurance , Insurance  will require providers to submit medical records without advance notice. In such cases, a Insurance  representative will visit the provider's office during business hours and secure the requested records immediately. The provider agrees to provide the requested records immediately. Members' contracts permit Insurance  to obtain medical records without a signed patient release.

4. The ordering/referring provider shall also provide medical records to the performing provider when requested for the purpose of medical necessity review. Additional documentation that is not a part of the medical record and that was not provided at the time of the initial request will not be accepted. Only records created contemporaneous with treatment will be considered pertinent. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.

5. If Insurance  determines that the patient services provided by the contracting provider are not medically necessary, the claim is denied and is a write-off to the provider. If the services are requested by the patient after being advised by the provider of the lack of medical necessity and the daily record or patient chart has been documented to that effect and a written waiver is obtained by the provider before the service being rendered, charges for the services will be the patient's responsibility.

Retrospective medical record review

Retrospective audits for medical necessity can occur after each member’s 14th office visit. Each chiropractor’s performance will be monitored on an individual basis. You must comply with your contractual obligations with BlueCross BlueShield of Western New York. Data will be maintained and reviewed by the Credentials Committee for re-credentialing purposes. Clinical measures - sources of information may include, but are not limited to utilization management reports, medical record reviews, and focused quality of care reviews.

Service measures - sources of information may include, but are not limited to information from grievances filed, member complaints, and member satisfaction surveys.

Medical Claims Review

Medical claims review staff review for medical appropriateness and adverse determinations for the following types of claims:

 Outpatient procedures and services
 Inpatient level of care
 Durable medical equipment
 Professional claims for inpatient and outpatient services
 All services where medical necessity determinations are to be made

The reviews are performed by health care professionals and administrative personnel, who determine:

 Contract eligibility
 Medical appropriateness
 Whether provider and member education is needed

Information regarding medical appropriateness review, adverse medical determinations, appeals
process, retrospective medical claims review, and the special investigations unit are located in
Section 5 of the BlueCross BlueShield Provider and Facility Reference Manual.


Patient charts

Proper documentation is your responsibility and extends beyond an internal office communication. Any similarly trained clinician should be able to review a chart and be able to understand the status of the patient on a visit-to-visit basis.

Documentation for all patient services must be dated and signed. Whiteout and excessive pen marks should not be used to modify or delete documentation. Notes should be legible and clearly substantiate medical necessity. If a legend is needed to review your records, please submit it with your records. If not supplied upon request, reimbursement will be denied for lack of medical necessity. BlueCross BlueShield does not consider travel cards as appropriate documentation. Most travel cards provide insufficient medical detail from which to determine the medical necessity of care and treatment performed.

Failure to meet these requirements may result in claim denial or claims returned for more information. The following medical record standards are minimally required; and based on the National Committee for Quality Assurance requirements and if not met, may result in delay or denial of reimbursement as a provider write-off. Additional information regarding NCQA can be found at

Each of the following components should be documented in the patient’s chart.

 Demographics
o Name/ID number: Every page of the medical record
o Date of birth
o Current address
o Home and work telephone numbers
o Emergency phone number
o Employer and work phone number
o Marital status

 Records documented in the Subjective, Objective, Assessment Plan (SOAP) format (additional information below)

 Related problem list
o List all significant illnesses and active medical conditions pertinent to the patient’s health care or “no problems”

 Allergies/adverse reactions
o Medication allergies and adverse reactions or NKDA/NKA must be recorded in a prominent location

 Relevant past history
o Includes serious accidents, operations, and physical and psychological conditions pertinent to the patient’s care

 Current medications/nutritional/herbal supplements or no medications

 History of presenting complaint
o List presenting symptom(s), potential triggering events, assessment of severity amount of pain and/or interference with daily activities, irritating/relieves symptoms, relation to activity, and previous treatment

 Pain chart completed by the patient

 Examination

o Vital signs: blood pressure, pulse, temperature, and respiratory rate
o Neurological exam

 Documented for at least the initial visit. The record should indicate that at least 80% of the pertinent examination has been recorded, and the follow-up neurological examinations are performed as clinically indicated.
o Orthopedic examination

 Orthopedic exam should be documented for at least the initial visit. The record should indicate that at least 80% of the pertinent examination has been recorded, and the follow-up orthopedic examinations are performed as clinically indicated.

 Imaging studies/laboratory studies

 Differential diagnosis and/or clinical impression
o Indicate the diagnosis/condition reflective of patient’s evaluation

 Treatment plan
o Number of treatments and intervals between visits (reasonable based on standards)
o Date and time frame for follow-up visits and discharge date

 Continuity of care between chiropractor and primary care provider or other referring specialist when indicated
o Written communication and/or documentation of telephone communications
o Need to include presenting symptom, likely diagnosis, and a treatment plan

 All entries in the medical record are signed and include dates for each visit.

SOAP notes

Please follow the SOAP format when documenting an office visit. The SOAP format includes:

Subjective data

This short statement describing the patient’s symptoms can be expressed by the mnemonic O, P1, P2, Q, R, S, and T.

 O-onset. When and how did chief complaint start?
 P1-provocative. What makes the pain worse (sit, stand, cough, bend, sleep, etc.)?
 P2-palliative. What alleviates the symptoms (rest, meds, ice, heat, etc.)?
 Q-quality. Pain characteristics (sharp, dull, achy, numb, radiating, stiff, tingle, burn, etc.)
 R-radiation. Where does pain refer to (arm, leg, head, etc.)?
 S-severity. Has the intensity of the pain changed since the last visit?
 R-Ratio on 0-10 scale. 1=mild, 5=moderate, 10=severe; or % improvement on a 0-100% scale
 T-tendency. Is the pain frequent or constant? 25, 50, or 75% of the time?

Objective data

This section records actual findings observed during the patient visit. Items in this section should include the following when appropriate:

 Observations, including postural evaluations
 Range of motion (ROM) of area of chief complaint
 Palpation findings including percussion, auscultation and motion palpation
 Orthopedic tests
 Deep tendon reflexes (DTRs), muscle tests, sensory exam
 Laboratory and diagnostic tests


The physician interprets the subjective and objective data to draw a conclusion about the patient’s current status. This section also includes the doctor’s initial diagnosis, impressions of the patient’s progress and evaluation of daily living activities.

Plan of treatment

The patient’s plan of treatment includes:

 Type of treatment provided which may include physical therapy. A brief description of techniques used is also helpful.
 Prescribed exercises or rest.
 Home therapy recommendations.
 Recommended frequency and duration of treatment. This could also include additional documentation regarding services referrals and coordination of care with other specialists.

All notes should be signed and dated by the clinician performing the services. At minimum, a legible first initial and last name is required; otherwise, the reimbursement will be denied. A stamped signature is not acceptable.

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