HD7 - The Feasibility of Creating a Universal Health Insurance Claims Form

  • Published: 1993
  • Author: State Corporation Commission
  • Enabling Authority: House Joint Resolution 241 (Regular Session, 1992)

Executive Summary:
The State Corporation Commission's Bureau of Insurance was requested by the 1992 General Assembly, pursuant to House Joint Resolution No. 241 (see Appendix A), to study the feasibility of creating a universal health insurance claims form for use by all insurance carriers licensed in the Commonwealth. The study was requested because (1) various and multiple claims forms which request duplicative and diverse information are a factor in administrative costs: (ii) completing these varying health insurance claims forms requires providers to have separate staff whose sole duty is to act as liaison for consumers and insurance carriers; and (iii) the dollars spent on administering health care could be more efficiently and effectively utilized on the provision and delivery of health care.

The Bureau surveyed the top twenty-five (25) writers of accident and sickness insurance policies in Virginia to determine whether they would be in favor of the creation of a single health insurance claims form. Out of nineteen (19) responses received, twelve (12) companies said they would be in favor of this proposal. Although the survey did not ask the respondents to comment on a particular form, several companies mentioned on the survey that they would not be opposed to the establishment of a universal claims form as long as it was the HCFA-1500 for providers and the UB-82 for hospitals. (see Appendix B). These are national forms that were developed by the Uniform Claims Form Task Force and the National Uniform Billing Committee. The Health Care Financing Administration co-chaired both of these groups together with the American Medical Association and the American Hospital Association, respectively. One company stated that the development, implementation, and required use of uniform claims forms could best be achieved by using the forms already developed at the federal level. Several other companies stated that they would be opposed to any form that was unique to Virginia.

The Bureau also surveyed one hundred (100) randomly selected physicians licensed and living in Virginia to determine whether they would be in favor of the development of a single health insurance claims form. Out of thirty (30) responses received, twenty-eight (28) said they would be in favor of such a proposal. Although the survey did not ask the respondents to comment on a particular form, several physicians stated that the HCFA-1500 is currently being used as a national form.

Eighteen (18) advisory organizations representing provider groups other than physicians were also surveyed. Out of sixteen (16) responses received, fifteen (15) indicated that they would be in favor of the creation of a universal claims form for health insurance. Several organizations mentioned the HCFA-1500 and the UB-82 claims forms.

The Bureau also researched the activities of the other states to determine whether any other states had adopted a standard health insurance claims form. Twenty-six (26) states have either adopted a standard claims form or are considering it. Thirteen (13) of these states either require or plan to require insurance to accept the HCFA-1500 claims form from physicians, and eleven (11) states either require or plan to require insurers to accept the UB-82 claims form from hospitals. Nine (9) states have adopted the claims form for pharmacists. The National Association of Insurance Commissioners (NAIC) is also in the process of setting up a working group to study this issue. Some preliminary information obtained from the NAIC indicates that they will probably recommend adopting the HCFA-1500 for physicians, the UB-82 for hospitals, and the ADA form for dentists. They have not decided what they will recommend for pharmacists.

Based on these findings, the Bureau recommends that all accident and sickness insurers, health maintenance organizations, health services plans, and dental and optometric services plans licensed in the Commonwealth be required to accept as standard claims forms:

(i) the HCFA-1500 claims form (or its successor) for physician services and for services provided by chiropractors, audiologists, speech pathologists, clinical nurse specialists who render mental health services, physical therapists, psychologist, clinical social workers, professional counselors, podiatrists, optometrists, and opticians;

(ii) the UB-82 claims form (or its successor) for hospital services; and

(iii) the ADA claims form developed by the American Dental Association for dental services.

Payors should not be prohibited, however, from accepting any other claims form that has been determined to be acceptable by both the provider and the payor.

Because there does not appear to be a national standard form already developed for use by pharmacists, the Bureau does not recommend establishing a pharmaceutical claims form that would be unique to Virginia. The Bureau recommends that the standardized format which is being developed by the American National Standards Institute to facilitate the electronic submission of claims be used by all insuring entities as soon as the ANSI X12 837 Health Care Claim Transaction form has been adopted (see Appendix C). This form will be available for use by hospitals, physicians, dentists, pharmacists, and other health care providers.