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Accuracy

The following are results from the National Health Insurer Report Card (NHIRC) years 2008-2013 that address accuracy.

Metric 4—Allowed amount disclosed 
Description: On what percentage of claim lines does the payer provide allowed amount (the amount the payer deems payable prior to considering patient responsibility) in its ERA response to the physician?1
Metric 4

Metric 4A—Class of Contract discolsed
Description:  On what percentage of claims is the class of contract field populated when there is more than one fee schedule amount associated with the claim filing indicator where the difference is not attributable to the application of claim edits or payment rules?

Aetna Anthem Cigna HCSC Humana Regence UHC
73.96% 
of all relevant claims  (20.38% of total claims)
35.64%
of all relevant claims (25.26% of total claims)
95.32%
of all relevant claims
(5.87% of
total claims)
93.17%
of all relevant claims
(9.96% of
total claims)
100.00%
of all relevant claims 
(5.79% of
total claims)
96.04%
of all relevant claims (24.01% of total claims)
99.03%
of all relevant claims
(6.45% of
total claims)

Metric 5—Contracted fee schedule match rate
Description: On what percentage of claim lines does the payer’s allowed amount equal the contracted fee schedule rate excluding the application of claim edits and payment rules (rules that adjust the fee schedule amount)?2
View the 2013 National Health Insurer Report Card results for the 95% confidence half-width.

Metric 5

Metric 5A – Contracted fee schedule match rate by major CPT code categories
Description: On what percentage of claim lines does the payer’s allowed amount equal the contracted fee schedule rate by major CPT code categories?2
View the 2013 National Health Insurer Report Card results for the 95% confidence half-width.

  Aetna Anthem Cigna HCSC Humana Regence UHC Medicare
E & M 98.47% 93.40% 98.34% 89.34% 98.00% 85.34% 99.24% 99.75%
Medicine 93.93% 87.59% 95.98% 91.16% 97.90% 89.00% 96.58% 99.32%
Pathology & Laboratory 98.60% 97.14% 99.40% 97.79% 99.35% 78.19% 99.53% 99.83%
Radiology & Imaging 94.78% 85.57% 95.25% 92.70% 96.35% 97.42% 97.61% 99.65%
Surgical 95.92% 89.58% 96.81% 93.86% 98.06% 98.53% 98.10% 99.60%

Metric 5B—Contracted fee schedule match rate by state**
Description: On what percentage of claim lines does the payer’s allowed amount equal the contracted fee schedule rate by state? Only states that met the minimum sample size of 500 were reported.
X= 95% Confidence Half-Width

  Aetna Anthem Cigna HCSC Humana Regence UHC
  % X % X % X % X % X % X % X
AL                  97.35%  1.21%     96.88% 1.42%
AR                  97.37%  0.98%     99.66% 0.25% 
AZ                         97.32%  0.56% 
CA  98.75%  0.07% 90.70% 0.11%  92.79% 0.47%             98.95% 0.46% 
CO  90.87% 2.51%  92.02% 1.27% 98.90%  0.68%      99.84%  0.32%      97.75% 1.16%
CT  99.25%  0.15% 95.36% 0.35% 99.38%  0.13%                 
DC                         95.84% 1.15% 
DE  99.11%  0.35%                        
FL  98.57%  0.20%     98.19%  0.25%     96.53% 0.29%     97.93% 0.27%
GA  95.86%  0.45% 93.45% 0.21% 97.30%  0.25%     99.03% 0.20%     97.73% 0.20%
IL             90.23% 0.33%            
IN     92.27% 0.29% 99.72% 0.21%     96.70% 0.73%        
KS 94.47% 1.23%                     98.59% 0.42%
KY 95.82% 1.25% 93.36% 0.19% 98.27% 0.36%     98.82% 0.17%     98.43% 0.49%
LA                 98.57% 0.33%     98.33% 0.90%
MD  99.49%  0.58%     94.50%  0.60%             96.92% 0.51%
MI 94.74% 1.61%             96.45% 0.93%        
MO 98.17% 0.68% 88.19% 0.93% 98.97%  0.54%     96.67% 1.31%     98.44% 0.31%
MS                 98.13% 0.74%        
NC  96.81%  0.72%     98.56%  0.43%             97.97% 0.26%
NE 96.12% 1.36%                        
NJ 93.09% 0.87%                        
NY 94.09% 1.85%                        
OH  85.35%  0.55% 90.97% 0.28% 99.09%  0.48%     97.95% 0.26%     98.12% 0.33%
OK  90.18%  2.20%             99.61% 0.55%     99.16% 0.73%
OR                     99.13% 0.44%    
PA 96.43% 1.43%     100.00% 0.00%                
SC         100.00%  0.00%              99.10% 0.37% 
TN  96.90%  0.64%     98.13%  0.23%     98.19% 0.16%     98.64% 0.45%
TX  93.75%  0.39%     98.10%  0.28% 93.34%  0.16% 96.41% 0.47%     98.39% 0.14%
VA  98.09%  0.44%     98.21%  0.50%             99.80% 0.38%
WA                     84.39% 0.41%    

Metric 6 – First ERA Accuracy
Description:  On what percentage of claim lines does the payer's allowed amount equal the physician practice's expected allowed amount?

Metric 6

15010 compliance note: This metric was changed to reflect the 5010 version of the HIPAA 835 electronic remittance advice standard transactions that requires the allowed amount to be reported when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by the implementation guide, do not send.
2
Only data reported by commercial payers that met the minimum sample size of 500 were reported.
* = New metric for 2013
** = May not total 100% due to rounding error  
HCSC = Health Care Services Corporation
UHC = UnitedHealthcare
NR= Not reported

The AMA NHIRC results are based on data pulled from the nationally mandated Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic standard transactions.  The technical references for these transactions are the electronic remittance advice (ERA) (HIPAA ASC X12 835 Health Care Claim Payment/Advice Transaction) submitted to a physician in response to the receipt of an electronic claim submission (HIPAA ASC X12 837 Health Care Claim--professional transactions).