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 * or CMS-1500 forms*

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' *

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.