You May Be Asked to Submit Member Charts for Retrospective Review

In coming weeks, you may be asked to submit individual member medical records to Highmark for review to comply with Centers for Medicare & Medicaid Services (CMS) requirements.

CMS requires Highmark to ensure the accuracy and integrity of diagnosis codes that providers have submitted on claims for payment. Those codes must have been documented in members’ medical records as a result of face-to-face visits with them.

All diagnoses must be coded according to the CMS International Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting.

Highmark began the chart retrieval process April 3, and providers are being contacted randomly to participate through Oct. 20.

What information is being reviewed?

Member medical records are being reviewed to verify that complete and accurate documentation exists to support confirmed or suspected chronic illnesses and conditions diagnosed during patient visits.

In some cases, diagnosis-related information contained in medical records doesn't get reported to Highmark via claims data. This program is intended to get a complete account of all diagnosis codes supported by medical record documentation and to evaluate the specificity of ICD-10-CM coding.

The initiative complies with applicable laws, rules and regulations, including the Health Insurance Portability and Accountability Act (HIPAA).

When and how will I be contacted?

You may be contacted any time from now through Oct. 20. If you are selected to participate in the chart review process, one of three approved Highmark vendors will contact your office or facility:

• CIOX Health (formerly known as ECS and Healthport)
• Verscend (formerly known as Verisk)
• ArroHealth (formerly known as MedSave)

According to the provisions of your Highmark provider agreement, you are required to supply copies of any requested member medical records to the vendor that contacts you. The vendor won’t ask you to submit original records. However, complete medical records must be submitted within 30 days of request and without charge.

The vendor will contact you most likely by telephone to verify the list of Highmark members’ names and to discuss methods for submitting their individual records. Then the formal request and list will be mailed or faxed to you.