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General Requirements

Before considering payment, we routinely require clinical documentation for these categories of claims:
 

  • Codes appended with a modifier indicating additional or unusual services (e.g., 22, 23, 24, 25, 51, 53, 57, 59 or 66)
  • Codes to which an assistant or co-surgeon modifier is attached that do not normally require an assistant or co-surgeons
  • An unlisted code as defined in the Index of CPT under Unlisted Services and Procedures
  • A code that is not otherwise specified (NOS)
  • A code that is not otherwise classified (NOC)
  • Procedures that are potentially cosmetic
  • Procedures that may be experimental, investigational or unproven
  • Procedures that are medically necessary for some indications and not for others
  • Services performed in an unexpected place of service, such as office services performed in an outpatient surgery center

Beyond these categories, we may require submission of clinical records before or after payment of claims. This will help us investigate potential fraudulent, abusive or other inappropriate billing practices. We will only request them if there is reasonable cause for an investigation.

This policy does not limit our right to require submission of medical records for prior authorization purposes.

Note: State legislation and/or plan-specific language supersedes administrative guidelines.
 

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