BULLETIN 2012-01

 

TO:

 

Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc. and Health Maintenance Organizations Offering or Renewing Insured Health Products in Massachusetts (“Insurance Carriers”)

FROM:     Joseph G. Murphy, Commissioner of Insurance
DATE:January 25, 2012
RE:Reporting to the Bureau of Managed Care (the “Bureau”) of Instances Where Insurance Carriers Are Not Consistent with Required Uniform Coding and Billing Standards


 

Coding

According to M.G.L. c. 176O, § 5A, Insurance Carriers and their subcontractors in Massachusetts must adopt, accept, and recognize patient diagnostic information and patient care service and procedure information consistent with the current Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) compliant code sets when processing claims for persons covered under insured health benefit plans issued in Massachusetts.  The HIPAA-compliant code sets include the:

  • International Classification of Diseases (ICD);
  • American Medical Association’s (AMA) Current Procedural Terminology (CPT); codes, reporting guidelines and conventions; and
  • Centers for Medicare and Medicaid Services Healthcare (CMS) Common Procedure Coding System (HCPCS).

Insurance Carriers and their subcontractors must adopt these HIPAA-compliant code sets, and all changes made to the code sets, in their entirety no later than the implementation date established by the coding standard entity.

Claim Formats

Insurance Carriers and their subcontractors also must use, without local customization, the standardized claim formats for processing health care claims as adopted by the National Uniform Claim Committee (NUCC) and National Uniform Billing Committee (NUBC).  Insurance carriers and their subcontractors must adopt and routinely process all changes to such formats by no later than the implementation date established by the format-setting entity.

Reporting Inconsistencies

The Bureau, within the Division of Insurance, has established a system for health care providers to report instances where a carrier may not be adhering to required uniform standards.  In the event that a provider believes a carrier not to be in compliance with the required standards, the provider may file a complaint with the carrier to attempt to resolve the complaint.  If the provider is not satisfied with the carrier’s response, the provider may file a report with the Bureau using the attached form.  In the event that a carrier has failed to respond to a provider’s complaint within 30 days, or if a provider believes that the complaint is about the same coding issue that had previously been submitted to the carrier, the provider may file a report with the Bureau without providing the carrier’s response.

The provider should have a certified coder review the complaint and sign the form confirming that, in the certified coder’s opinion, the carrier failed to comply with the required coding or billing guidelines.  In the event that a provider does not have access to a certified coder, the provider must make every effort to ensure that coding guidelines were not adhered to by the carrier and should state the reason that a certified coder was not available to sign the form.

 

The Bureau will review the information provided and may obtain additional information as it deems necessary in order to determine any action that may be needed.  The Bureau may initiate carrier audits and may consult with the Statewide Advisory Committee on Uniform Coding and Billing established by M.G.L. c. 176O, § 5B in relation to future actions. 

If you have any outstanding questions, please contact Nancy Schwartz, Bureau of Managed Care Director, at 617-521-7347.

 

 

REPORT OF INSTANCE WHERE INSURANCE CARRIER IS NOT CONSISTENT WITH REQUIRED UNIFORM STANDARDS FOR BILLING AND CODING

ProviderName 
 Address 
 Contact Name 
 and Phone No. 
 Contact e-mail 
Health planName 
 Address 
   

 

Identify the code(s) or billing format that you used and that was not accepted by the insurance carrier.  Attach a copy of the insurance carrier’s disposition, the complaint you sent to the insurance carrier about its failure to accept uniform coding or billing format, and the response you received from the insurance carrier. ______________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Explain verbatim the official coding or billing guidelines upon which you base your complaint, as well as any other appropriate reference.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

Attach copies of supporting clinical, registration or billing documentation that pertains to the rejection in question.

_____________________________________________________________________________________

_____________________________________________________________________________________

Describe the resolution sought.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

I confirm that, in my opinion, the insurance carrier failed to comply with the required coding or billing guidelines:

 

Signature of certified coder _________________________________Date__________________

 

Send to: Bureau of Managed Care via U.S. Mail to Bureau of Managed Care, 1000 Washington Street, Suite 810, Boston, MA 02118 or via FAX to 617-521-7750 or via e-mail to BMC.mailbox@state.ma.us  with a Copy to:  Subject Insurance Carrier