Specialists: We may request patient medical records

 

Under a current program, we may ask to review selected medical records. We do these reviews to compare the clinical coding to the corresponding clinical services provided to our members.

We base these requests on either:

• The characteristics of the claim (such as the charges billed in conjunction with the procedure performed).
• The provider who submitted the claim (due to different billing practices compared to those of his/her peers).

Affected specialties:

• Dermatology
• ENT
• Hand surgery
• Neurology
• Neurosurgery
• Orthopedic surgery
• Pain management
• Physiatry
• Plastic surgery
• Podiatry
• Sports medicine
• Urology

Affected procedures
We may request to review medical records for the following procedures:

• Dermatology - excisions, complex repair, tissue transfer and flaps.
• Urology - cystoscopy, urethroscopy, transurethral surgery and prostate procedures.
• Other specialties - spine surgery, breast reconstruction, hand surgery, arthroscopy, debridement, complex closures, tissue transfer, endoscopic sinus surgery, anesthesia by surgeons, excisions, flaps and unlisted procedures.

When we request medical records, fax them to Aetna at 859-455-8650