Minimum Required Documentation for Claims

 Visits 

To be claimed as an insured service, the minimum record of a visit must include: 

(a) patient identification which includes the patient’s name and MCP number, 

(b) date of service for which payment is being claimed, 

(c) reason for the visit e.g. presenting complaint or other reason for that visit, and 

(d) findings through history, physical examination, working diagnoses, and/or plan of investigation or treatment.

Timed Based Services

(a) Where a premium fee is applicable based on the time the service is rendered, the starting time indicator for that service must appear in the patient’s record. (For home visits, an approximate time will be sufficient). (b) Where the fee payable is based on time units, the start and finish times for time unit fees for which payment is being claimed, must be part of the patient record of that service.

Procedures 

When a procedural fee is claimed, the patient record of that procedure must contain information which is sufficient to verify the type and extent of the procedure according to the fee(s) claimed. For all services listed in the In-Hospital Diagnostic, Radiology, and Nuclear Medicine Sections, the date of service is the date the service is reported rather than the date the patient is subject to the procedure. For all other services, date of service is the date of patient contact.

 For additional documentation requirements, refer to the specific codes being claimed.

Independent Consideration (IC)

Specific services in this Schedule are designated as billable on an IC basis only. Physicians are required to identify claims for these services as IC and to provide additional applicable information, according to instructions in this Schedule or the Physician’s Information Manual (PIM).

Services not specifically defined in this Schedule, or for which a set fee is not listed, must be billed IC. For these services an IC claim must include:

(a) the time involved in direct continual attendance with the patient or in performing the procedure claimed, whichever applies, 

(b) a list of all examinations and procedures performed which are represented by the claim, 

(c) the actual size of lesions removed or laceration repaired, or the area of any defect which was repaired, if applicable, 

(d) comparison in scope and difficulty of the procedure with other procedures defined in the Payment Schedule, and 

(e) a copy of the operative report along with the actual operating time for complex surgical procedures. 

New technology services which are under review by DHCS may be billed IC with approval by DHCS. 

Use of Provider Number

Claims must be submitted using the Provider Number of the physician who actually rendered or directly supervised the service. 

Physicians are required to request prior approval from MCP for all arrangements where payment is to be directed to a designated payee. The claim must indicate a designated payee in the Payee Number Section.

Time Limitations on Claim Submission 

All claims must be submitted within 90 days of the date of service. In exceptional circumstances this time period may be extended as per the MCP Late Claims Policy which is available on the MCP website. A letter giving a full explanation for lateness must be submitted to the Manager of Claims Processing for special consideration.

 All queries from MCP must be answered within the times specified on the queries. If no time is specified, a reply must be received within 90 days of the date of query. 

All requests for changes to claims and queries on them must be submitted within 90 days after the date of payment for the claims concerned.