Blue Cross Newsletter
 

November 23, 2010

BC-10-17
HP-10-13
DC-10-12
MS-10-14

SA-10-13
HHA-10-13
ASC-10-11

To: All Blue Cross Contracting Providers
From:

Cindy Garrison, CPC – Education/Communication Coordinator
Institutional Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association

Subject:

Medical Records Request

 

Before some claims can be processed, Blue Cross and Blue Shield of Kansas will request medical records in order to determine if medical necessity and/or criteria has been met.

Sometimes the information being requested is not in any of the records at the facility.  When this happens, it is up to the facility to obtain the essential documentation from the referring physician.  Should the facility have difficulty obtaining the requested records from the ordering physician, the facility can contact their provider consultant for assistance.

If the ordering physician decides to send in the requested records directly to BCBSKS, they will need to include a copy of the medical request letter that was sent to the facility.  This way, BCBSKS can match the records with the claim needing the information for processing.  If BCBSKS cannot identify which claim needs the records, the records will be returned to the ordering physician.

BCBSKS will only request the necessary documentation once.  We will make a decision on how to process the claim based on what records are received as a result of the request.  If the records received do not support the medical necessity and/or criteria for the service, the claim will be denied.

If the provider feels the denial is incorrect and they have obtained the essential documents, they may file a written inquiry.  The inquiry to verify the original determination should be made within 180 days of the date of the remittance advice (RA) if done in 2010 and 120 days of the date of the RA if done in 2011.  It is vital that you do not use the word appeal in your written notice when you send the required documentation to support the medical necessity and/or approved criteria of the service.  It is helpful if providers include a copy of the RA showing the denied claim. 

The inquiry step is optional.  Providers can skip this step and proceed straight to the appeal process.  However, if the provider does the inquiry review step and disagrees with the inquiry review decision, the provider may send a written appeal notification of the disagreement to BCBSKS.  This initial appeal must be submitted within 180 days of the date of the RA.  Providers should include the word appeal in this written notification.  See your Policies and Procedures for complete details regarding the appeal process.  All requested medical records must be provided at the initial appeal.

As indicated in Section II of the Policies and Procedures, the Contracting Provider shall not bill BCBSKS members for medically unnecessary services unless the members have been notified in advance that specific services, which they are going to receive, will be their responsibility. 

Providers wishing to send a written inquiry review or appeal should send their request, along with the necessary documentation, to:

Attn: Customer Service Center
Blue Cross and Blue Shield of Kansas
1133 Topeka Blvd
Topeka, KS  66629-0001

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