Delayed "Clean Claims" Rules In Place

Implementation of new Maryland Insurance Administration regulations aimed at standardizing health insurance claims and speeding claims payment has been delayed until September. Originally expected to take effect in May, the so-called "clean claims" regulations now will apply to all claims received by payers on and after September 7, 2001. The following are some of the key features of the rules, which may help standardize some claims payment practices. 

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    HCFA standards for completion of a Form 1500 will be, in  effect, law in Maryland. Payers must accept a properly completed HCFA Form 1500 "and instructions provided by HCFA for use of the HCFA 1500 as the sole instrument for filing claims." A fully completed Form 1500 that contains all of the essential information is a clean claim, and a payer cannot demand additional information to justify payment, except as provided in the rules regarding attachments.

    The regulations limit payers to 12 circumstances in which they can require attachments to accompany the HCFA 1500 in the first instance. For example, carriers no longer will be able routinely to demand submission of office records with a claim. Now payers will be allowed to demand office records only if the claim included modifier 21 or 22, or the payer's audit of the practitioner "demonstrated a pattern of improper billing." Importantly, physicians are free to supply more than the essential data elements or allowed attachments if they wish, but carriers cannot require more than the specified elements or attachments.

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    Carriers cannot use their own peculiar codes, or "local codes," meaning that the entire CPT code regime is required. Carries cannot require physicians "to use any code or modifier...that is different from, or in addition to, what is required under the applicable standard code set for the professional service provided,"except in connection with a global contract (contract involving one payment for services of multiple practitioners). With regard to physician claims, the term "applicable standard code set" is defined to mean the current version of the CPT, "including its codes and modifiers, and codes for anesthesia services."

    Mandatory use of the full CPT regime and HCFA standards for completion of the Form 1500, MedChi believes, means that payers cannot ignore parts of the CPT regime, e.g. they no longer can ignore modifiers. Controversy on this point is anticipated, but MedChi believes that other provisions of the regulations support it. Importantly, the rules state that a payer may not challenge the sufficiency of a claim based on a policy or protocol "that is inconsistent with the applicable standard code set." Thus, the CPT Manual should become a standard book for claims processing.

    Anticipating disputes about claims on which payers may demand additional information, the rules set categories of "legitimate" and "illegitimate" disputes. In order to limit the grounds on which payers may challenge the sufficiency of a claim and its documentation, the regulations enumerate "permissible categories of disputed claims for which third-party payers may request additional information." The biggest of these is a dispute based on medical necessity, but it applies only if there was no authorization, or if there was a pre-authorization and the carrier disputes the claim consistent with the retroactive denial law, or the service was beyond the scope of the preauthorization.

    The regulations set out a standard for judging when a claim is received by payers. Payers are required to maintain a record of the date they receive every claim, written or electronic. Payers are required to furnish verification of the date of receipt upon request by a provider within five working days from the date of request. The date on the payer's log is presumed to be correct, unless the provider has obtained a stamped certificate of mailing from the post office showing the mailing date, in which case the claim is presumed to have been received 3 days from the date on the certificate. The post office will issue a certificate of mailing for 75 cents for any piece of mail, but the item must be mailed at the post office.

Do you have questions about clean claims regulations? 
Call MedChi at 800-492-1056, ext. 321 or e-mail sbrunt@medchi.org.