March 4, 2003 Bottom Line

Bottom Line: Documentation for Private Health Plans

Audiologists and speech-language pathologists frequently call ASHA in search of documentation templates and advice on how to streamline paperwork while still ensuring reimbursement for their services. Unlike Medicare, which has published specific documentation guidelines, private health plans often have unique documentation requirements. This article will focus on documentation tips for private payers.

Does a universal documentation template exist?

A. No. The way in which an SLP or audiologist documents what they do is influenced by many factors. One template could not possibly meet the needs of all facilities, clinicians, and payers. Different facilities or agencies have varying requirements for how services are to be documented (e.g., SOAP notes, narrative formats) and where notes are to be maintained (e.g., carbonless copies, writing notes directly in the patient's chart, electronic medical record).

Payers may have their own documentation requirements, including the information they want to see when reviewing a claim and the timelines in which documentation must be submitted. According to a spokesperson from the American Association of Health Plans, documentation requirements can vary from contract to contract, even within one health plan. A contract between health plan A and employer B may differ, for example, from that between the same health plan and employer C. Each contract may specify unique data points that must be collected through documentation. Typically, health plans are instructed by law to request only the minimum information necessary to pay a claim.

What other factors influence how we document what we do?

A. In addition to facility requirements and clinical judgment, federal regulations also apply, most notably the Health Insurance Portability and Accountability Act, which includes stipulations for electronic data exchange and privacy. Accrediting and regulatory agencies—including the Joint Commission on Accreditation of Healthcare Organizations, the Commission on Accreditation of Rehabilitation Facilities, and the National Committee for Quality Assurance—set general documentation standards that must be considered.

Can documentation really be streamlined?

A. Yes. Despite the requirements listed above, it is possible to develop a documentation process—in the form of templates, a computerized system, or narrative outlines—that will require less time and optimize reimbursement. Contact the private payers you bill and request a copy of their documentation requirements. Spend time as a staff developing the most appropriate documentation process for your facility.

The choice is yours—spend the time up front ensuring appropriate documentation and reimbursement, or spend the time after the fact, filing appeals for denied claims.

Amy Hasselkus is ASHA's associate director for health care services in speech-language pathology. For more information on documentation, contact her through the Action Center at 800-498-2071, ext. 4514, or by e-mail at


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