Claims Requiring documentation to be submitted with the claim Providers are required to submit additional documentation (e.g. physician notes, operative notes, discharge summary, consultant reports, etc.) for adjudication of the following types of claims. If the provider does not furnish the additional documentation or information, the claim is not considered a clean claim and (PLAN) will deny payment without being liable for interest or penalties.

• Claims for unlisted, non-specific, or miscellaneous codes. Due to rapid advances in medicine, physicians and providers may provide services, procedures and supplies that do not have specific codes (CPT or HCPCS). Therefore no fees or RVU is assigned. An allowance will not be permanently established for unlisted codes, since these codesare used to describe many different procedures payment may be subject to review of a report. A clear description of the service provided must be included. NOTE: Additional supporting documentation may be required for unlisted procedure codes.
• Claims for services requiring clinical review (e.g. complicated or unusual procedures)
• Claims for services that are reimbursed based on purchase price (e.g. custom DME, prosthetics)
• Claims for beneficiaries with other health insurance (OHI)
• Claims requiring documentation of the receipt of an informed consent (e.g. sterilization, hysterectomy)
• More than one Evaluation and Management visit code billed by the same provider (or providers with a group of the same specialty) for the same member on the same date of service.

Claims where additional documentation may be requested by Claims and/or Medical Review. (PLAN) may request additional documentation or notify the provider of additional documentation requirements needed in order to complete claim processing. If the provider does not furnish the additional documentation or information, the claim is not considered a clean claim and (PLAN) will deny payment without being liable for interest or penalties.

• Claims for services found to possibly conflict with medical necessity of covered benefits to covered persons (e.g. new technology, potential experimental or investigational procedures or devices, potential cosmetic procedures)
• Claims where additional documentation may be needed after manual review of the claim submission and the claim coding and claim history does not offer enough information to complete processing. (Example claims submitted with modifier 22, 53, 59, 25, 24, and 57)
• Claims requiring a Certificate of Medical Necessity (e.g. motorized wheelchairs, lymphedema pumps, oxygen)
• Claims being reviewed for potential fraud or abuse.
• Claims for services found to possibly conflict with covered benefits to covered persons after review of members’ medical records (e.g. member eligibility)
• Appealed claims where supporting documentation has not been provided and/or is incomplete for a claim determination of payment to be made.