/policies/,/policies/administrative/,/policies/administrative/uw-health-administrative/,/policies/administrative/uw-health-administrative/fiscal-affairs/,

/policies/administrative/uw-health-administrative/fiscal-affairs/225.policy

201712356

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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Fiscal Affairs

Patient Right to Amend Billing Records (2.25)

Patient Right to Amend Billing Records (2.25) - Policies, Administrative, UW Health Administrative, Fiscal Affairs

2.25

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals
and Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations
and staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).

Policy Title: Patient Right to Amend Billing Records
Policy Number: 2.25
Effective Date: December 19, 2017
Chapter: Fiscal Affairs
Version: Revision

I. PURPOSE

To provide a mechanism for appropriately correcting billing records at the request of the patient or a
healthcare provider.

II. POLICY ELEMENTS
A. All patients and their legally authorized representatives have a right to request an amendment of
their UW Health billing records. Only UW Health Revenue Cycle staff are authorized to make
amendments pursuant to the procedures described below.
1. A "legally authorized representative" is anyone who is authorized under state law to
request an amendment to an individual's billing records. State law determines the age and
ability of an individual to request an amendment to a billing record. Any questions about
the age or ability of an individual to request an amendment should be directed to the UW
Health Office of General Counsel.
2. Billing Records are defined as records maintained by UW Health that reflect patient
demographics including patient/guarantor information, third party payer details,
payments, referrals, charges, diagnoses and procedures entered in Health Link or
financial statements and correspondence related to collection activity.
B. Clinical or clinical support staff may also have a clinical or business need to amend designated
billing records.
C. UW Health has the right to deny an amendment under certain conditions. All denials will be
documented.
D. Revenue Cycle staff must take reasonable measures to verify the identity and authority of the
person requesting to amend the billing records. Examples of how this may be accomplished
include: (1) requiring the requester to provide detailed information corresponding with the
request, such as birth date, medical record number, treatment date etc.; (2) requiring written
request; (3) verifying the clinicians’ involvement in the treatment; or (4) requiring photo ID or
other documents such as guardianship or Power of Attorney (POA) papers.




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III. PROCEDURE
A. Request to Amend Billing Records
Patients, their legally authorized representatives, or UWHC staff ("authorized parties") who
believe that the information contained in a patient's billing record is incorrect may request an
amendment to the billing record. All such inquires and disposition of any request will be handled
by Revenue Cycle staff.
B. Review/Response Process
1. Authorized party requests changes to patient's billing record (demographics, diagnoses).
Requests for changes to the billing record can be written or verbal.
a. The Account Representative will review current information and requested
changes and respond within 7 days or else request an extension in order to
complete the review.
b. Authorized party will be notified of requested changes to the billing record.
c. Billing record changes involving updated insurance information will result in the
submission of claims to appropriate third party payers. Any payments made in
error will be refunded.
2. Authorized party disputes the diagnosis.
a. The Account Representative will route the account for coding review in Health
Link.
b. The Coder will review the medical record and determine what diagnoses and
procedures should be entered based on the documentation in the chart.
c. If the Coder determines the diagnoses should be revised, the Coder enters
corrected diagnoses to the account in Health Link. The billing record is corrected
to reflect the revision. Claims are resubmitted as appropriate.
d. If current documentation does not support request for amended codes, provider
will be informed of request by coder and given opportunity to review
documentation and determine if amendment is appropriate.
e. If the Coder determines the diagnoses are correct according to the documentation
in the medical record, the Account Representative communicates to the party
requesting the amendment that the diagnoses cannot be amended.
C. Denial Process
1. UWHC may deny the request for amendment of the billing records if the records are
accurate and complete, for example:
a. The authorized party disputes billing records (demographic information) and
there is information to support the information on file.
b. The authorized party disputes the diagnosis and the Coder determines the
documentation in the chart supports the diagnosis and the provider confirms that
documentation is accurate.
2. If a request by a patient or their legally authorized representative is denied in whole or
part, UW Health must provide the patient with an explanation that includes:
a. The reason for the denial.
b. An explanation of their right to submit a written statement disagreeing with the
denial and instructions on how to file a statement of disagreement.
c. Inform the patient that if they do not choose to file a statement of disagreement,
they may alternatively request in writing that UWHC provide copies of both the
request and the denial in any future disclosures.
d. A description of how the patient may file a complaint with UW Health pursuant
to the complaint procedures listed in UW Health’s Notice of Privacy Practices.
e. Upon patient request, this explanation will be provided in writing.

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3. Statement of disagreement. UW Health will allow the patient or their legally authorized
representative to submit a written statement disagreeing with the denial.
4. Rebuttal process. UW Health may choose to prepare a written rebuttal to the statement of
disagreement, but if done, the patient or the legally authorized representative must be
provided with a copy.
D. Making the amendment
If Revenue Cycle staff agree to make the amendment:
1. Patients or their legally authorized representative will be sent a copy of the "Request to
Amend Billing Records" form, which will list the diagnoses changes that have been
made.
2. If warranted, Revenue Cycle staff will correct the diagnosis in the billing record and the
claim will be resubmitted to the patient's third party payer.
3. Authorized party will be notified of requested demographic changes to the billing record.

IV. COORDINATION

Sr. Management Sponsor: VP, Revenue Cycle
Author: Director, Coding;
Reviewer(s): Director, Patient Access; Director, Registration; Director, Revenue Cycle

Approval committee: UW Health Administrative Policy and Procedure Committee


SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer