• A
  • |
  • A
  • Text size

Administrative Burden Index - Score 5

Administrative burden associated with undisclosed claim edits

Data for these scores are taken from the NHIRC "Metric 10": Percentage of total claim lines reduced to $0 by undisclosed claim edits.[1]

"Metric 10" outlines on what percentage of claim lines does the payer apply a claim edit, which the payer has not disclosed on its website or in other provider communications, that reduces the payment (allowed amount) of the claim line to $0.

An online claim editing tool that requires manual entering of each and every code pair to determine whether an edit will apply does not meet this definition.[2]

“Readily accessible information,” as used in the NHIRC, on edits means that a qualified health care professional that accesses payer policy statements and payment rule information from the payer’s website is able to exactly create the full scope of a specific edit rule without additional information from the payer.

The AMA's goal is that applied claim edits be 100 percent publically sourced.  The lack of transparency of payer-specific edits adds substantial administrative costs for physicians trying to reconcile claims.


[1] All scores in the Administrative Burden Index refer to metrics outlined in the National Health Insurer Report Card. Visit www.ama-assn.org/go/reportcard for full metric descriptions and methodology.

[2] To be considered a “disclosed edit” for the purposes of the NHIRC, the complete scope of an edit rule must be disclosed. Access “2013 National Health Insurer Report Card: Statement of methodology, including the step-by-step guidance” for more detailed information. 

What can physicians do after reviewing ABI scores?

Scoring and five-star ratings

The ABI score was created to assist physicians in identifying the cost of doing business with the participating payers in the NHIRC.  For simplicity, a grading scale, similar to educational system grading scales which use 0-100 point scales, was utilized.  An exception was made so that a score of 100 points was required to receive five stars, instead of the traditional 90-100 points for the top grade.

Therefore, an ABI score of:

  • 100 is equal to five stars
  • 90-99 is equal to four stars (95-99 is awarded an additional ½ star)*
  • 80-89 is equal to three stars
  • 70-79 is equal to two stars
  • 60-69 is equal to one star
  • 59 or lower is equal to zero stars

*Payer scores of 95-99 that fell in the 4 star category were given additional recognition of a ½ star to acknowledge their efforts to reach the AMA goals.