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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 forms* (PDF)
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 appended with a modifier indicating additional or unusual services (e.g., 22, 23, 24, 53, 59, or 66)
- Exception: The following modifiers do not require clinical records
- Any HCPCS modifiers
- CPT modifiers 25, 26, 52, 63, or 90
- codes to which an assistant or co-surgeon modifier is attached that do not normally require 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/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
Types of clinical documentation that may be requested include:
- ER notes
- facility notes
- anesthesia notes and time
- facility/MD notes
- operative notes
- radiology interpretation and report
- lab results
- MD office notes
Beyond the above categories, CIGNA HealthCare may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is reasonable basis for believing such investigation is warranted.
This policy is not designed to limit CIGNA HealthCare's right to require submission of medical records for precertification purposes.
Note: State legislation and/or plan-specific language supercede CIGNA HealthCare administrative guidelines.
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