FREQUENTLY ASKED QUESTIONS

What Provider types are under review?
CGI Technologies and Solutions Inc. (“CGI”) is a third-party vendor retained by Highmark, Inc. (“Highmark”) to conduct reviews of inpatient, outpatient and professional paid claims as part of the Highmark’s review program to prevent fraud, waste, abuse and material misrepresentation. This program is designed to ensure the accuracy of claims reporting, ensure proper application of member benefits, assist practitioners in identifying claim reporting aberrant patterns and provide opportunities for further education of Highmark’s network providers regarding its policies and procedures.

The types of reviews conducted by CGI on behalf of Highmark may include:

• Coding and clinical validation of codes resulting in increased reimbursement
• Appropriateness of items or services provided and adherence to applicable standards of practice
• Adherence to Highmark’s Administrative and/or Medical Policies
• Validation of claim charges impacting overall claim reimbursement.

How are claims selected for review?
CGI uses proprietary software and systems, as well as knowledge of associated rules and regulations to determine case selection.

Who will be reviewing my claim?
For those claim reviews that require medical record review, CGI will utilize experienced staff from the appropriate discipline based on the audit type. CGI’s audit staff contains a variety of credentials including medical doctor (MD), registered nurse (RN), registered health information administrator (RHIA), registered health information technician (RHIT), certified coding specialist (CCS), certified professional coder (CPC), clinical documentation improvement practitioner (CDIP), therapists, and pharmacists (R.Ph.).

Will all reviews be conducted at the facility or provider location?
No, a determination of whether to conduct an onsite review will be made based on the scope and volume of medical records to be reviewed.

If an onsite review is scheduled, how many CGI staff will be assigned to review at the provider site?
Assignment of staff is dependent on the scope of the review and the volume of the medical records to be reviewed.

What is done to protect confidential data during a review?
CGI protects and limits exposure of PHI data and has policies in place to protect this information. Paper documents are delivered to a secured zone, where they are received and imaged into the system, and records delivered via media are imported into Proper Pay. CGI removes, clears, sanitizes or destroys sensitive information, in accordance with set policies and procedures. Proper Pay is SQL database-driven and web-enabled. No confidential data is stored on workstations or laptops because of the nature of the application design.

What criteria does CGI use as guidelines when performing reviews?
CGI utilizes various reference materials such as Highmark Medical and Reimbursement Policies, Provider Resource Network (PRN) articles, Article VIII of the Bylaws of Highmark Inc., Provider Regulations, Provider Manual, ICD-9, ICD-10, CPT, and HCPCS coding guidelines applicable to the date of service of the claim. We also reference AHA Coding Clinic and AMA CPT Assistant, as well as internally-developed clinical parameters based on current peer-reviewed medical literature and consensus statements from nationally-recognized medical associations.

Will CGI accept additional information, such as office notes, to support the request for services?
Yes, CGI encourages providers to submit all supporting documentation with the initial response to the medical record request. During the initial discussion period, supporting evidence for a request for services will be accepted.

What are the claim review status definitions?
A high-level explanation of the claim review statuses are available under the CGI Information links on the Highmark Portal home page.

What is the Address for Medical Record submission?
Please submit medical records to:
CGI Technologies and Solutions Inc.
Attn: Imaging Center
140 University Park
Troy, AL 36081

What is the Due Date for Medical Record submission?
Medical Records are due as stated in the medical record request letter.

I am unable to meet the deadline. May I request an extension?
Yes, you may request an extension by contacting Highmark Call Center at (877) 817-5954. E-mail Address: Highmark.helpdesk@cgi.com.

Will CGI pay for postage?
No, CGI does not pay for copying or postage fees.

In what formats can medical records be submitted?
Records are accepted in the following formats: paper, CD or DVD, and electronic.

What are the requirements for Paper Medical Records?
Paper medical records must meet the following requirements:

• Free of staples and paperclips.
• Photocopy must be of good quality and legible.
• Include a copy of the CGI Highmark Medical Record Request Letter.
• Records may be copied on both sides; top faced and face up.

What are the requirements for Imaged Medical Records?
CGI encourages providers to submit documents in imaged format. Imaged records must meet the following requirements:

• Scanned image resolution must be 200 dpi and in black and white.
• Image must be in the TIFF format, with Group 4 compression, or in PDF format. CGI would prefer the TIFF format. For the use of any other formats, please contact the CGI Highmark Helpdesk at (877) 817-5954 prior to sending the files.
• Multi-page documents must be in one image file. For example, a 50 page medical record will be one image file.
• The scanned images must be legible.
• The image file naming convention must be as follows; [Patient Name]_[Admit Date/Date of Service]. For example, if the Patient Name is John Smith and the date of service is October 1, 2008, then the file will be named JohnSmith_10012008.tiff.
• Include a copy of the Highmark Medical Record Request letter and the record list with the CD/DVD. Please refer to encryption instructions below for details.

May I load the Medical Records via the Highmark Web Portal?
Yes, CGI encourages providers to submit medical records via the Highmark portal medical records upload process.

• To upload medical records via secure website, go to the following address: https://hmportal.cgicleve.com.
• Click on the “PROVIDERS” link at the top of the page and login.
• Select the “Medical Records Submission” option.
• Select the applicable Letter Type.
• Select the Letter ID.
• Select the Claim Number from the letter that you received.
• Click the “Browse” button to navigate to the appropriate PDF or TIFF records on your hard drive.
  Please make sure the records selected are for the claim number that was selected.
• Click the “Add” button to add the records to the upload grid.
• After all files are added to the upload grid, click the “Upload” link to start the upload process.
• The “Medical Record Upload Status” page will then display the uploaded files.
• Note: For more detailed instructions, refer to the “USER GUIDE” link after logging into the Highmark Web Portal. You must be logged in to see the “MR Submission” instructions in the Provider Functionality section. Only PDF or TIFF files can be uploaded. If you have questions or problems with the upload process, please call CGI Highmark Helpdesk at (877) 817-5954.

If we submit more than one DVD, do the DVDs need to be labeled 1 of 3, 2 of 3, 3 of 3?
Yes, we recommend the following as shown in the example:
MercyHospital_20091212_1, MercyHospital_20091212_2, MercyHospital_20091212_3.

May we place all DVDs in one package and provide one copy of the CGI Documentation Request Letter?
Yes, please note if there is more than one Documentation Request Letter, all copies should be included in the package.

If I send records on a CD or DVD, do they need to be encrypted?
For security purposes, all images sent via CD/DVD must be encrypted using a WinZip file that is password protected, or by using PGP encryption. Please notify CGI when using another encryption format besides WinZip.
For encrypted WinZip files:

• Encrypt the CD/DVD only; not the individual medical record files on the ADR Letter
• For encrypted WinZip files: Use your Medical Record Request Letter ID as the password. For Providers that use a version of WinZip that requires 8 characters to encrypt, please place zeros BEFORE the Letter ID; i.e. 00075231.
• For encrypted PGP files: Contact CGI prior to shipment to obtain the Public Encryption key. This can be accomplished by calling our Highmark Call Center at (877) 817-5954.

What is a Medical Record Request Letter
A Medical Record Request Letter contains a list of claims which require a review of the associated medical record documentation to reach a determination.

What is a Findings Letter?
A Findings Letter contains the result of CGIs initial review of the paid claims, which may include medical records review. This letter gives the provider the opportunity to review the findings and submit an appeal in writing.

What is a Semi-Automated Findings Letter?
A Semi-Automated Findings Letter contains the result of basic CPT rules violations. This letter gives the provider the opportunity to review the findings and respond to any violations noted in the letter, by submitting medical records for review. All records submitted for review with a finding will generate a findings letter to which the provider may submit an appeal for additional review.

What options do I have if I do not agree with some or all of the findings in the Findings Letter?
If you are in disagreement with the findings, please submit a request for appeal, in writing, within 21 calendar days from the date of this letter.
You are encouraged to include the additional information (including medical records) that you feel would help support the services billed as well as your rationale.
All supporting documentation will be reviewed and the provider will be notified of the final determination in an Appeal Determination Letter.

What is an Appeal Determination Letter?
An Appeal Determination Letter contains the result of the appeal review conducted by CGI at the request of the provider.

If you disagree with the Appeal Determination, you may have the option to request external review via an Independent Review Organization (“IRO”).* If you choose this option, your request must be received in writing and indicate your IRO selection from the two entities noted. You may submit any supporting materials you wish to have considered by the IRO. All supporting materials must be provided to CGI within five (5) days following the submission of your written request for external review. CGI will forward your request and supporting materials to Highmark, and Highmark will send the case to your selected IRO for review. Once the IRO renders a decision, Highmark will inform you of the decision in writing.

To facilitate the processing of your response, please include a copy of this letter with any correspondence regarding this matter, and direct your request for IRO review to the following address:

CGI Technologies and Solutions Inc.
ATTN: Imaging Center
140 University Park
Troy, AL 36081

Please be advised that if we do not receive notification of either your agreement or your request for external review within thirty (30) calendar days from the date of the Appeal Determination Letter, it will result in automatic recovery of overpayment(s) by Highmark, as established in your Provider agreement.

*The availability of any external review option is subject to the terms of your Provider/Network Agreement. Please refer to your Provider/Network Agreement and the Highmark Provider Manual for more information about the specific external review options available in your region.

For additional information on the Highmark payment review process, please refer to Chapter 6, Unit 8 of the Highmark Provider Manual.