April 2018

Medical Record Submission ‘Dos and Don’ts’

In certain cases, Blue Cross and Blue Shield of Oklahoma (BCBSOK) may need to request additional information to process a claim, such as medical records, operative reports or other supporting documentation – In such cases, BCBSOK will only request the minimum Protected Health Information (PHI) necessary per the Health Insurance Portability and Accountability Act (HIPAA).

It is very important that you submit only the information that is requested and only if it is requested. Below are some quick reminders on when and how to submit medical records and other information:

DO:

• Use the letter you receive from BCBSOK as your cover sheet when submitting the requested information to us. This letter contains a barcode that will ensure we match the requested information directly to the appropriate file and/or claim.
• Use the Claim Inquiry Resolution (CIR) to submit specific information that was requested in the claim denial, such as medical records, operation reports and physician notes through the Availity^TM Electronic Refund Management (eRM) system. For more information view the CIR Tip Sheet.
• For providers and administrators registered with Availity^TM you may receive and send electronic quality and risk adjustment medical record requests to and from BCBSOK. For additional details, refer to the Responding to Electronic Quality and Risk Adjustment Medical Records Requests Tip Sheet.

Please Note: Electronic medical record request and submission process are not available for medical record requests resulting from utilization review activities or the claims adjudication process. We anticipate offering additional capabilities throughout 2018.

• Submit only the information that pertains specifically to what is requested by BCBSOK.

DON’T:

• Do not submit a Claim Review form in addition to the letter you receive from BCBSOK, as this could delay the review process. 

POST-ADJUDICATION INQUIRIES:

Do not automatically submit medical records for claims that have been denied due to "not a covered benefit" or similar reasons. If you submit medical records for claims that have already been denied for these reasons, you will receive a letter from BCBSOK alerting you that your request will not be reviewed because the services performed are not eligible for coverage under the patient's benefit plan.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSOK. BCBSOK makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.