Medical record documentation and signature requirements

Copies of medical records, utilization review documentation, and/or itemized bills related to claims may be requested by Anthem Blue Cross and Blue Shield (Anthem) for the purposes of reimbursement validation and other healthcare operational functions or submitted by the provider to initiate a reimbursement dispute.

These functions may include but are not limited to: conducting audits and reviews, validation of correct coding requirements, and documentation review of services rendered in accordance with reimbursement policies.

Anthem recognizes the importance of medical record documentation and standards that require providers and facilities to maintain medical records are detailed in Reimbursement Policy Documentation Standards for Episodes of Care – Professional. These standards include:

• Patient’s name and date of birth should appear on all pages of record.
• Patient’s condition(s) should be clearly documented in record.
• Documentation must be dated, if applicable, and start and stop time must be documented.
• Physician’s/qualified non-physician’s signature, rendering provider credentials (for example, MD, RN, etc.), and date must appear on record and must be legible to someone other than the writer.

It is important that medical documentation is clear, concise, complete, and specific indicating that the condition(s) was monitored, evaluated, assessed/addressed, or treated (MEAT), or there is evidence of treatment, assessment, monitoring, or medicate, plan, evaluate, referral (TAMPER). The documentation describing the condition and MEAT or TAMPER must be legible.

If a provider is using abbreviations, standard and appropriate abbreviations are requested. Please be aware that some abbreviations have different meanings; use the abbreviation that is appropriate for the context in which it is being used.

Medical records submitted that are not compliant with above guidelines are subject to claim denials and/or recoupments.

* Please note medical records submitted for clinical purposes may be exempt from this policy (utilization management, prior authorization, etc.). Approved prior authorizations are not a guarantee of payment.