Clean Claim Requirements

What is a Clean Claim?

At Cigna Healthcare^SM, 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-10) codes, tenth revision
• accurate entries for all the fields of information contained in the UB04 [PDF]¹ or CMS-1500 forms [PDF]¹

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

Claims Requiring Clinical Documentation

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 '1'¹
• modifier 59 - Non-Evaluation & Management (E/M) service codes that disallow with a CMS/NCCI Mutually Exclusive Edit designated by CMS as '1'¹

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 Healthcare combinations that require documentation is available on the Cigna for Health Care Professionals website at 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 our right to require submission of medical records for precertification purposes.²

Editing Claims with Cigna Healthcare

ClaimsXten Clear Claim Connection^TM, our code edit disclosure tool powered by McKesson, allows users to enter CPT and HCPCS coding scenarios and to immediately view the audit result. Clinical edit rationales, as well as edit sourcing, are provided for any code that is not allowed in Clear Claim Connection.

Clear Claim Connection is accessible through the Cigna for Health Care Providers portal at CignaforHCP.com. Once logged on, you may review the Clear Claim Connection Frequently Asked Questions for more information.

Cigna Healthcare is committed to providing solutions that can minimize your administrative costs while helping to reduce the complexity of doing business with us.