Maintaining Insurance Claim Files

Chapter 4: Revenue Management

Insurance Claims, Denied Claims and Appeals, and Credit and Collections

4-3 Maintaining Insurance Claim Files

The management of insurance claim files is crucial for both compliance with regulations and effective billing practices. In this regard, several points should be understood clearly:

Patient Request for Remittance Advice

  • Patient Identification Privacy: If a patient requests a copy of the remittance advice received by a provider, it is essential to redact all patient identification information except for that of the requesting patient. This protects the privacy of other patients involved in the document.

  • Example of Redaction: For instance, if a patient requests a copy of the transmittal notice related to their last date of service, the office should make a copy of the relevant page, remove any identifying details of other patients, and send the redacted copy to the requesting patient. The remaining part of the document containing other patients' information should be shredded to maintain confidentiality.

Retention of Insurance Claims

  • CMS Requirements: The Centers for Medicare & Medicaid Services (CMS) mandates that providers keep copies of government insurance claims and all attached documents for a minimum of six years unless longer retention is required by state law. This duration allows for the possibility of audits during that time frame.

  • Electronic Claims Compliance: Providers and billing services that file insurance claims electronically can meet CMS retention requirements by keeping the original source document (e.g., routing slip, charge slip, encounter form, or superbill) from which the claim was derived. This also includes retaining the emailed report summarizing electronic claims received from the insurance company.

Types of Claims and Organization

It's advisable for providers to securely store claims as either electronic claims files or manual claims files.

  • Open Claims: These are claims submitted to the payer that are still pending processing. They are organized by month and insurance company and include claims that were rejected due to errors or omissions, which need to be reprocessed.

  • Closed Claims: Claims for which all processing has been completed, including any necessary appeals, are categorized as closed claims. These should be filed according to year and insurance company.

  • Remittance Advice Documentation: Remittance advices should be organized chronologically based on the date of service since payers often report results of insurance claims processed on the same date for various patients, compiling these into a batched remittance advice.

Other Claim Types

  • Unassigned Claims: These claims are generated for providers who do not accept assignment and are organized by year. They involve claims that the provider is not obligated to follow up.

  • Denied Claims: Claims may be denied by payers due to various issues like coding errors, missing information, or patient coverage problems. Denied claims are considered unpaid, returned claims that require revision. The reasons for denial are typically detailed in the remittance advice (remit) or explanation of benefits (EOB), with any coding errors or coverage issues being specified. Denied claims remain classified as open claims until the appeal process has been fully executed.