806 KAR 17:370. Standardized health claim attachments

Section 1. Definitions. (1) "Clean claim" is defined by KRS 304.17A-700(3). (2) "Health benefit plan" is defined by KRS 304.17A-005(22). (3) "Health care provider" or "provider" is defined by KRS 304.17A-700(9). (4) "Health claim attachments" is defined by KRS 304.17A-700(10). (5) "Insurer" is defined by KRS 304.17A-005(29) . (6) "Limited health services benefit plan" is defined by KRS 304.17C-010(5). (7) "Practitioner" means an individual licensed or certified to provide a health care service in Kentucky. (8) "Reparation obligor" is defined by KRS 304.39-020(13). Section 2. Standardized Health Claim Attachments. If another payment source is identified by a provider, an insurer shall require the provider to include the following health claim attachments, as applicable, for a claim to qualify as a clean claim: (1) An explanation of benefits statement or noncoverage notice from another payer; (2) An electronic or paper-based Medicare remittance notice if the claim involved Medicare as a payer; and (3) A record of all payments by a reparations obligor pursuant to KRS 304.39-010 to 304.39-340. Section 3. Routinely-requested Health Claim Attachments. An insurer offering a health benefit plan or a limited health service benefit plan for dental only, may routinely request the following health claim attachments in accordance with KRS 304.17A-706(2), as applicable: (1) A certification of medical necessity; (2) A complete medical record, or part of a medical record, including: (a) Discharge summary: 1. Patient identification, including name, age, gender, and medical record number; 2. Name of attending practitioner; 3. Dates of admission and discharge; 4. Final diagnosis; 5. Reason for the admission or visit; 6. Medical history; 7. Significant findings during length of stay or visit; 8. Procedures and treatments; 9. Patient condition at discharge; 10. Discharge medications; and 11. Discharge instructions; (b) Emergency department report: 1. Patient identification, including name, age, gender, and medical record number; 2. Date of service; 3. Attending practitioner; 4. Chief complaint and symptoms; 5. History of present illness and physical exam; 6. Diagnostic test findings; 7. Clinical impression and diagnosis; 8. Treatment plan; 9. Discharge instructions; and 10. Practitioner orders; (c) History and physical: 1. Patient identification, including name, age, gender, and medical record number; 2. Chief complaint; 3. Details of present illness; 4. Relevant past, social and family histories; 5. Inventory by body system; 6. Summary of psychological needs; 7. Report of relevant physical exam; 8. Statement relating to the conclusions or impressions drawn from the admission history and physical; 9. Statement relating to the course of action planned for this episode of care; and 10. Name of practitioner performing history and physical; (d) Nurse's notes: 1. Patient identification, including name, age, gender, and medical record number; 2. Vital signs with graphics, if available; 3. Intake and output record, if applicable; 4. Medication administration records; 5. Date of nurse's notes; 6. Nurse assessment; 7. Nursing intervention; 8. Observation; and 9. Name of nurse; (e) Operative report: 1. Patient identification, including name, age, gender, and medical record number; 2. Date of procedure; 3. Name of operating practitioner; 4. Pre- and post-operative diagnoses; 5. List of procedures performed; 6. Operative description including indications and findings; 7. Anesthesia used; and 8. Specimens collected; (f) Progress notes: 1. Patient identification, including name, age, gender, and medical record number; 2. Discharge or treatment plan; 3. Practitioner orders; 4. Practitioner notes; 5. Attending practitioner name; 6. Results of tests and treatments; 7. Dates of notes; and 8. Chief complaint; (g) Test results: 1. Patient identification, including name, age, gender, and medical record number; 2. Test findings, including date ordered and date completed; and 3. Ordering practitioner name; (h) Practitioner orders or treatment plan, as applicable: 1. Patient identification, including name, age, gender, and medical record number; 2. Practitioner orders; 3. Ordering practitioner name; and 4. Order dates; (i) Practitioner notes: 1. Patient identification, including name, age, gender, and medical record number; 2. Practitioner name; 3. Practitioner notes; and 4. Dates of notes; (j) Consult notes and reports: 1. Patient identification, including name, age, gender, and medical record number; 2. Practitioner name; 3. Findings and recommendations including notes and reports; and 4. Dates of notes and reports; (k) Anesthesia record: 1. Patient identification, including name, age, gender, and medical record number; 2. Administering practitioner name; 3. Start and stop anesthesia times; 4. Route of administration; 5. Dates; 6. Notes; 7. Patient vital signs; and 8. Drug administered; (l) Therapy notes: 1. Patient identification, including name, age, gender, and medical record number; 2. Practitioner name; 3. Practitioner orders; 4. Treatment plan; 5. Number of treatments and dates; 6. Therapist's notes; and 7. Dates of notes; (m) Office notes: 1. Patient identification, including name, age, gender, and medical record number; 2. Practitioner name; 3. Any notes generated for dates of service; and 4. Dates of notes; (n) Dental records; and (o) Pharmacy records; (3) Certification and documentation as identified in 42 C.F.R. 441.203, 441.206, 441.207, 441.208, 441.250, 441.255, 441.256, and 441.258; (4) Itemized bill; and (5) Evidence of Medicare secondary payment pursuant to 42 C.F.R. 411.32.