June 21, 2006

BC-06-10
HP-06-08
SA-06-08

HHA-06-08
DC-06-08

All Blue Cross Contracting Providers

Medical Record Requests and Submission Procedures

Most claims that providers send to BCBS can be processed based on the codes that are included on the claim.  There is however times when medical records are needed before a claim can be finalized.  Medical records might be needed when:

• the medical necessity for a service is not clear;
• high cost/utilization services are provided; or
• an agreement with a specific group requires certain services be reviewed.

Providers located in the Kansas company service area submit all of their claims to BCBSKS.  This includes claims for local members (enrolled in BCBSKS) as well as out-of-area members (enrolled in BCBS in another state).  If a claim for either a local or out-of-area member requires medical records, you’ll receive that request from BCBSKS.  Providers will also return those records to BCBSKS.

The procedures for requesting and submitting medical records are different depending on whether the claim is for a local member or an out-of-area member.   Here’s how the processes work:

Medical record procedures for claims involving LOCAL MEMBERS

When a claim for a local member requires medical records:

• BCBSKS temporarily denies the claim for more information.
• BCBSKS sends a letter to the provider outlining the specific records needed. 
• The provider resubmits the claim to BCBSKS with the records attached.
• BCBSKS finalize the claim.

BCBSKS expects that medical records for local members be submitted timely.

Medical record procedures for claims involving OUT-OF-AREA MEMBERS

National BlueCard handling procedures requires that BCBSKS track medical record requests.  BCBSKS is graded on the timeliness of the provider’s response and the return of the records to the member’s home plan. 

When a claim for an out-of-area member requires medical records:

• The member’s home plan tells BCBSKS what records they need,
• BCBSKS faxes a letter to the provider clearly stating what records are needed.
• The letter asks that the records be faxed to BCBSKS within 10 days of the date of the letter.  A mailing address is also provided.
• BCBSKS tracks the medical records request awaiting the provider’s response.
• Providers submit the medical records to BCBSKS within 10 days of the date of the request.  Fax submission is preferred.
• BCBSKS forwards the records to the member’s home plan for review and claim finalization.  (When records are faxed to BCBSKS we can redirect the fax onto the member’s home plan without converting the information to paper.)   

Because BCBSKS is graded on how timely records are provided to the member’s home plan, we strongly encourage that all records for out-of-area claims be faxed to us within 10 days of the date of the request.  We believe that the ability to request and submit medical records via a fax process is HIPAA compliant.

We also believe that the timely turnaround of all medical records (for both local and out-of-area members) not only enhances the overall claim processing cycle but also allows providers to satisfy State requirements that apply to record requests made by patients or their designee. 

We appreciate your commitment to not only providing quality healthcare services but to making claim and medical information available in the requested timely manner that will enhance the claims process.

If you have questions about BCBS claims, contact:

          Local members:          Topeka Local          (785) 291-4180
                                             Toll Free                   1-800-432-3990
                                     
          Out-of-area members:   Topeka Local          (785) 291-4058
                                                 Toll Free                 1-800-432-3990 ext. 4058
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