Accuracy
The following are results from the National Health Insurer Report Card (NHIRC) years 2008-2012 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 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 |
| 92.04% of all relevant claims (17.69% of total claims) |
42.08% of all relevant claims (21.66% of total claims) |
95.29% of all relevant claims (8.75% of total claims) |
55.07% of all relevant claims (7.00% of total claims) |
99.97% of all relevant claims (6.32% of total claims) |
80.67% of all relevant claims (52.08% of total claims) |
99.96% of all relevant claims (5.19% of total claims) |
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 2012 National Health Insurer Report Card results for the 95% confidence half-width.
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 2012 National Health Insurer Report Card results for the 95% confidence half-width.
| Aetna | Anthem | Cigna | HCSC | Humana | Regence | UHC | Medicare | |||||||||
| E & M | 97.72% | 90.18% | 94.86% | 91.30% | 91.80% | 90.46% | 98.84% | 99.99% | ||||||||
| Medicine | 93.04% | 83.59% | 91.82% | 88.33% | 86.57% | 71.43% | 97.76% | 99.92% | ||||||||
| Pathology & Laboratory | 97.95% | 95.87% | 95.44% | 95.95% | 84.75% | NR | 99.26% | 99.81% | ||||||||
| Radiology & Imaging | 95.86% | 88.45% | 86.40% | 84.68% | 86.82% | NR | 99.07% | 99.88% | ||||||||
| Surgical | 95.15% | 87.02% | 89.42% | 94.13% | 92.42% | NR | 98.15% | 99.92% | ||||||||
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 | 100.0% | 0.00% | ||||||||||||
| AR | 93.0% | 1.92% | 94.0% | 2.06% | 98.2% | 0.80% | ||||||||
| AZ | 99.7% | 0.31% | 94.8% | 1.10% | 75.4% | 3.55% | ||||||||
| CA | 96.9% | 0.15% | 91.6% | 0.13% | 85.4% | 1.09% | 99.23% | 0.75% | ||||||
| CO | 92.1% | 1.78% | 99.2% | 0.68% | ||||||||||
| CT | 95.2% | 0.53% | 58.5% | 1.41% | ||||||||||
| DC | 96.4% | 0.70% | ||||||||||||
| FL | 98.9% | 0.15% | 93.1% | 0.46% | 95.9% | 0.28% | 99.32% | 0.11% | ||||||
| GA | 98.4% | 0.34% | 87.5% | 0.33% | 96.5% | 0.42% | 85.1% | 0.69% | 98.7% | 0.17% | ||||
| HI | ||||||||||||||
| IA | 48.0% | 4.16% | 86.9% | 2.62% | ||||||||||
| IL | 95.7% | 0.92% | 97.8% | 0.85% | 92.1% | 0.31% | 94.7% | 1.81% | ||||||
| IN | 89.7% | 0.53% | 99.1% | 0.73% | ||||||||||
| KS | 99.5% | 0.31% | 71.0% | 2.88% | 20.4% | 1.73% | ||||||||
| KY | 82.9% | 0.42% | 78.8% | 0.63% | ||||||||||
| LA | 97.0% | 1.23% | 98.5% | 0.59% | 94.7% | 0.56% | 98.9% | 0.32% | ||||||
| MA | 76.1% | 1.54% | ||||||||||||
| MD | 94.1% | 0.56% | 95.0% | 0.60% | 99.5% | 0.18% | ||||||||
| ME | 91.6% | 2.29% | ||||||||||||
| MI | 95.5% | 1.59% | ||||||||||||
| MN | 98.7% | 0.64% | ||||||||||||
| MO | 86.1% | 1.19% | 84.0% | 1.34% | 89.0% | 1.13% | 97.3% | 0.88% | ||||||
| MS | 96.2% | 1.11% | 89.8% | 1.73% | 98.7% | 0.87% | ||||||||
| MT | ||||||||||||||
| NC | 95.6% | 0.56% | 89.7% | 0.82% | 92.0% | 0.71% | 98.9% | 0.29% | ||||||
| NE | 97.6% | 0.45% | ||||||||||||
| NH | ||||||||||||||
| NJ | ||||||||||||||
| NM | ||||||||||||||
| NV | 86.3% | 2.86% | 99.4% | 0.49% | ||||||||||
| NY | 95.5% | 1.63% | 51.8% | 3.74% | ||||||||||
| OH | 93.2% | 1.06% | 90.5% | 0.39% | 99.6% | 0.32% | 94.9% | 0.85% | 97.8% | 0.41% | ||||
| OK | 93.0% | 1.38% | 98.4% | 0.88% | ||||||||||
| OR | 84.5% | 1.80% | ||||||||||||
| PA | 99.2% | 0.56% | ||||||||||||
| SC | 99.7% | 0.45% | ||||||||||||
| SD | ||||||||||||||
| TN | 99.1% | 0.47% | 93.4% | 0.66% | 91.7% | 1.05% | ||||||||
| TX | 91.2% | 0.50% | 90.5% | 0.48% | 91.2% | 0.16% | 91.6% | 0.51% | 98.6% | 0.12% | ||||
| UT | 95.3% | 1.72% | 99.4% | 0.28% | ||||||||||
| VA | 93.1% | 1.96% | 93.8% | 1.39% | ||||||||||
| WA | 100.0% | 0.00% | 86.3% | 1.47% | ||||||||||
| WI | 91.9% | 1.70% | ||||||||||||
| WV | ||||||||||||||
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?
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.
2Only data reported by commercial payers that met the minimum sample size of 500 were reported.
* = New metric for 2012
** = 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).
