Health Provider Clean Claim Requirements

Clean Claim Requirements

At CIGNA, our goal is to process all claims at initial submission. Before we can process a claim, it must be a "clean" or complete claim submission, which includes the following information, when applicable:

• primary carrier Explanation of Benefits (EOB) when CIGNA is the secondary payer
• prescription for physical therapy
• itemization of dates for physical therapy from facility
• prosthesis invoice
• trip notes for ambulance transport
• standard Diagnostic Related Groupings (DRG) or Revenue codes (facility)
• standard Health Care Procedure Coding System (HCPCS) code sets and modifiers
• standard Current Procedural Terminology (CPT®) code sets and modifiers
• standard International Classification of Diseases (ICD-9) codes, 9th revision
• accurate entries for all the fields of information contained in the UB04 * (PDF) or CMS-1500 forms* (PDF)

The following modifiers do not require clinical records: CPT modifiers 26, 52, 63, or 90

Except as noted, we routinely require clinical documentation at the time a claim is submitted for the following categories of claims to be considered complete:

• codes to which an assistant surgeon modifier (80, 81, or 82), assistant-at-surgery modifier (AS), or co-surgeon modifier (62) is attached that do not normally require surgical assistance 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/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
• codes appended with a modifier indicating additional or unusual services (e.g., 22, 23, 24, 53, 59, or 66)
• modifier 25 - Evaluation & Management (E/M) service codes that disallow with a CMS/NCCI Incidental Edit (also called Column 1/Column 2 Code Edits) designated by CMS as '1' *
• modifier 59 - Non-Evaluation & Management (E/M) service codes that disallow with a CMS/NCCI Mutually Exclusive Edit designated by CMS as '1' *

*Claims processing will not be delayed when the submission of supporting documentation is indicated in box 19 of the electronic claim submission or when attached to a paper claim. When supporting documentation is indicated on an electronic claim submission, the supporting documentation can be mailed to CIGNA address on the back of the patient identification card.

The supporting documentation requirement is on selected code edits when modifier 25 or 59 is billed. It is not an across the board requirement for all uses of these modifiers. A specific list of CIGNA combinations that require documentation is available on the secure CIGNA for Health Care Professionals website at www.cignaforhcp.com. To view, click on 'Resources > Claim Editing Procedures'.

Types of clinical documentation that may be requested include:

• emergency room notes
• facility notes
• anesthesia notes and time
• facility/MD notes
• operative notes
• radiology interpretation and report
• lab results
• MD office notes

This policy is not designed to limit CIGNA's right to require submission of medical records for precertification purposes.

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