Reimbursement Policy

Reimbursement policy is not intended to dictate medical practice. To the extent that there are any conflicts between Reimbursement Policy and the member or provider agreement language, the member or provider agreement language will be followed.

Policy Updates and Dissemination

Regence Reimbursement Policy is evaluated and updated on a routine basis. Regence Reimbursement Policy is communicated through provider newsletters or letters and is published online in the Reimbursement Policy Manual.

Requests for Review

Any disagreements with a reimbursement policy determination made by Regence can be submitted by contacting your provider consultant in writing. The request should include additional references or literature not reviewed in the initial policy determination. Follow our appeals process for specific claim billing disputes and appeals.

Correct Code Editor (CCE)

Regence utilizes Medicare’s National Correct Coding Initiative (NCCI) as the basis for correct coding. Regence has also created our Correct Code Editor (CCE) that identifies code pair edits to supplement the Centers for Medicare & Medicaid Services (CMS) NCCI edits.

Reimbursement for Duplication of Medical Records
Regence BlueShield will reimburse you for the cost of duplicating medical records when we have requested the records for utilization management purposes including:

• Medical necessity
• Prior authorization
• Discharge planning
• Case management

When requesting reimbursement, please submit a bill or invoice along with the duplicated records. All bills for medical records must be submitted along with the requested records to be eligible for reimbursement.

Duplicate Records reimbursement rates are as follows:

• 25 pages or less: $5.00
• More than 25 pages: $5.00 for the first 25 pages, plus .10 cents for each additional page

Please do not submit invoices for an outside vendor who is providing you with copying services. Our policy states that we do not reimburse this type of vendor for duplication of medical records. In addition, any X-rays and/or pictures that are submitted with the records will be returned to you as we do not reimburse for duplication of X-rays and pictures.

Please include the following information with the bill or invoice:

• Copy of original claim
• Total amount of charges
• Number of pages duplicated
• Member’s name and member identification number
  To whom the check should be made out to (e.g., clinic or medical group)
  Provider’s name, address, telephone number and tax identification number

Please do not include a CPT code on the invoice.

Revised February 2010

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