Clean Claim Requirements

At CIGNA HealthCare, 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 HealthCare 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 UB-92* (PDF) or CMS-1500 claim forms* (PDF)

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

CIGNA generally requires clinical documentation at the time a claim is submitted to be considered complete or "clean" for the following categories of claims (exceptions noted):

• codes appended with with an assistant surgeon modifier (80, 81, or 82), assistant-at-surgery modifier (AS), or co-surgeon modifier (62) which typically do not require surgical assistance or co-surgeons
• 'unlisted code' as defined in the CPT manual (under 'Unlisted Services and Procedures')
• codes that are 'Not Otherwise Specified' (NOS)
• codes that are "Not Otherwise Classified' (NOCC)
• procedures that are potentially cosmetic
• procedures that may be experimental/investigational/unproven
• procedures that are medically necessary for some indications and not for all indications
• 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)
• speciied Evaluation & Management (E/M) service code pairs submited with modifier 25 that are disallowed according to a National Correct Coding Initiative (NCCI) Incidental Edit (also called Column 1/Column 2 Code Edits with CMS '1' modifier designations*
• specified Non-Evaluation & Management (E/M) service code pairs submitted with modifier 59 that are disallowed according to a National Correct Coding Initiative (NCCI) Mutually Eclusive Edit with CMS '1' modifier designations*

*Not all NCCI edits require supporting documentation with initial claim submissions. Please see the Modifier 25 and Modifier 59 Code Lists requiring submitted documentation. The lists are available under Resources/Modifier & Reimbursement Policies.