Concerning clean claim requirements for health carriers
Section 1 Authority
This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§ 10-16-109 and 10-1-109, C.R.S.
Section 2 Scope and Purpose
This regulation outlines the requirements to determine whether or not a claim will be considered a clean claim, as well as the requirements for carriers processing each as required for a prompt payment of claims.
Section 3 Applicability
This regulation applies to any entity that provides health coverage in this state including a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a sickness and accident insurance company, and any other entity providing a plan of health insurance or health benefits subject to Article 16 of the insurance laws of Colorado. This regulation also applies to those long-term care companies that submit claims on the CMS 1450 and CMS 1500 claim forms.
Section 4 Definitions
A. “Additional information” means, for the purposes of this regulation, information beyond what was submitted with the initial claim that is required to enable a carrier to determine its liability and resolve a claim.
B. “Carrier” shall have the same meaning as found at § 10-16-102(8), C.R.S.
C. “Clean claim” means, for the purposes of this regulation, a claim for payment of health care expenses with all essential fields completed with correct and complete information required by the carrier to determine its liability.
D. “Essential field” means, for the purposes of this regulation, a field on a claim form, whether electronic or in any other form, that is not only required according to standards set forth by The Health Insurance Portability and Accountability Act (HIPAA), but is also necessary for the carrier to determine its liability and resolve the claim.
E. “Pended claim” means, for the purposes of this regulation, a claim which is held in an open or suspended status until requested additional information needed to resolve the claim is received or for at least thirty (30) days after a request for additional information is sent, whichever occurs first.
F. “Supplemental field” means, for the purposes of this regulation, a field on a claim form, whether electronic or in any other form, that is required or necessary only when it clarifies or quantifies the information in an essential field of a claim.
G. “Timely submit” means, for the purposes of this regulation, to provide to a carrier information or documentation requested within the time period required by § 10-16-106.5(4)(b), C.R.S.
H. “Unclean claim” means, for the purposes of this regulation, a claim for which information in the essential fields is missing, incorrect or incomplete, and additional information is needed by a carrier to determine its liability to resolve the claim.
Section 5 Rules
A. Clean claims shall be submitted in the appropriate format (electronic or paper) as required, must utilize the appropriate form (the American Dental Association Dental Claim Form, the CMS 1500 Form, or the CMS 1450 (UB-04) Form) or electronic equivalent, and shall include all essential fields necessary for the carrier to determine its liability and resolve the claim. In the case of a dispute over the status of a claim as clean or unclean, the Division shall make the final determination as to what fields are essential.
B. When all of the information or documentation necessary to resolve a claim is initially provided in the appropriate claim form or format that includes all of the essential fields and any supplementary fields needed for that claim, the claim shall be considered a clean claim and processed within the timeframes specified in § 10-16-106.5(4), C.R.S.
C. A carrier shall send a request for additional information necessary to resolve an unclean claim within thirty (30) calendar days after receipt of the claim pursuant to § 10-16-106.5(4)(b), C.R.S.
D. A carrier shall pend an unclean claim, as defined in Section 4.H. of this regulation, and hold such claim in an open or suspended status until requested additional information needed to resolve the claim is received or for at least thirty (30) days after a request for additional information is sent, whichever occurs first.
E. A carrier shall not deny an unclean claim, as defined in Section 4.H. of this regulation, for lack of required or incorrect information without requesting the information needed to determine its liability and without allowing the required time period for the additional information to be submitted.
F. A claim shall not be considered unclean if the information provided in the required format is missing or incorrect unless that information is an essential field or is required by the carrier to determine its liability and resolve the claim.
G. A carrier shall pay interest as appropriate pursuant to § 10-16-106.5(5), C.R.S., when clean claims are not paid, denied, or settled within the specified time periods.
H. A carrier shall pay interest pursuant to § 10-16-106.5(5), C.R.S., when additional information necessary for resolving an unclean claim is not requested within the required time period or when the carrier denies an unclean claim without holding the claim in a pended status for at least thirty (30) days or until the information is received, following a request for additional information.
I. A carrier shall pay a penalty equal to twenty percent (20%) of the total amount ultimately allowed on all claims not paid, denied or settled within ninety (90) days after receipt of the claim.
Section 6 Additional Information
A. A claim with all required fields completed is not considered “clean” if additional information is needed in order to resolve the claim. Carriers may request additional information only if the carrier’s claim liability cannot be determined with the existing information on the claim form and the information requested is likely to allow a determination of liability to be made.
B. When additional information is required, the carrier shall make the specific request in writing within thirty (30) calendar days after receipt of the claim. If information is being requested from a party other than the billing provider, the provider shall be notified that additional information is needed to adjudicate the claim. The specific information required shall be requested within thirty (30) calendar days after receipt of the claim form and identified for the provider upon request.
C. Additional information requested must be related to information in the essential fields of the claim. This applies even though the genesis of the request may be from other sources, e.g., if the carrier has other information that indicates the information in an essential field is incorrect, such as previous claims that indicate the treatment was for work-related injuries when the claim submitted indicates otherwise. Requests for additional information to determine if the treatment is medically necessary would be related to the fields specifying the services provided.
D. A carrier is not permitted to request additional information for the purpose of determining medical necessity when the claim form has all essential and supplementary fields correctly completed and the services were preauthorized pursuant to § 10-16-704(4), C.R.S.
E. The following circumstances are those for which additional information is generally required by most health carriers:
1. When the coverage is not primary, an explanation of benefits form from the primary payer;
2. When service/procedure codes indicate “unusual” procedural services or anesthesia, the medical records to justify medical necessity;
3. When surgical procedures utilize multiple surgeons or surgical assistants, the medical records to justify medical necessity;
4. When the procedure is a repeat procedure, the medical records to justify medical necessity;
5. When supplies and materials are ordered on an outpatient basis, the medical records and/or invoice to justify medical necessity or allowable fee; and
6. When services are billed using a “by report” or unlisted CPT code, the medical records to substantiate the claim.
F. If a managed care plan requires medical or other records on all claims for particular types of services/procedures or diagnosis codes, the carrier must clearly disclose such requirements in the provider contract, provider manual, or provider manual updates. If a carrier contracts with an intermediary, the carrier shall be responsible for making sure the intermediary provides such disclosure to contracted providers in a timely manner.
G. When requesting medical records, carriers must identify the particular component(s) of the medical record being requested or indicate the specific reason for the request, e.g., progress reports for most recent three months, or records to establish the medical necessity of the treatment provided. The records requested must be related to the service/procedure of the claim and limited to the minimum amount of information necessary. Requests for “all medical records” are not specific enough and would not be an acceptable request for claim adjudication.
H. Medical information requested from institutional providers shall be limited to the following:
1. History and physical reports;
2. Consultant reports;
3. Operative reports;
4. Discharge summaries;
5. Emergency department reports;
6. Diagnostic reports; and
7. Progress reports.
Section 7 Severability
If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected.
Section 8 Incorporated Materials
The Centers for Medicare and Medicaid Services “CMS 1500 Form”, published by the National Uniform Claim Committee shall mean “CMS 1500 Form” as published on the effective date of this regulation and does not include later amendments to or editions of the “CMS 1500 Form.” The Centers for Medicare and Medicaid Services “CMS 1500 Form” may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado 80202 or by visiting the Centers for Medicare and Medicaid Services Website at http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/16_1500.html. Certified copies of The Centers for Medicare and Medicaid Services “CMS 1500 Form” are available from the Colorado Division of Insurance for a fee.
The Centers for Medicare and Medicaid Services “CMS 1450 (UB-04) Form”, published by the National Uniform Billing Committee shall mean “CMS 1450 Form” as published on the effective date of this regulation and does not include later amendments to or editions of the “CMS 1450 Form.” The Centers for Medicare and Medicaid Services “CMS 1450 Form” may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado 80202 or by visiting the Centers for Medicare and Medicaid Services Website at http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/15_1450.html. Certified copies of Tthe Centers for Medicare and Medicaid Services “CMS 1450 Form” are available from the Colorado Division of Insurance for a fee.
The American Dental Association “ADA Dental Claim Form,” published by the American Dental Association shall mean “ADA Dental Claim Form” as published on the effective date of this regulation and does not include later amendments to or editions of the “ADA Dental Claim Form.” The American Dental Association “ADA Dental Claim Form,” may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado 80202 or by visiting The American Dental Association Website at http://www.ada.org/7119.aspx. Certified copies of the American Dental Association “ADA Dental Claim Form” are available from the Colorado Division of Insurance for a fee.
Section 9 Enforcement
Non-compliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.
Section 10 Effective Date
This regulation is effective January 1, 2014.
Section 11 History
Emergency Regulation 02-E-7, effective July 2, 2002.
Temporary Regulation 02-T-7, effective October 1, 2002.
Regulation 4-2-24 effective February 1, 2003.
Amended Regulation 4-2-24 effective February 1, 2008.
Amended Regulation effective June 1, 2012.
Amended Regulation effective January 1, 2014.