1. WellChoice does not encourage paper submissions of claims. Electronic claims submitted to WellChoice should be routed using a HIPAA-compliant software vendor or clearinghouse. However, if you need to submit a hard copy, physicians are required to use a HCFA 1500 form and facilities use a UB92 form.
2. A completed claim form should include all patient information, including the WellChoice member identification number, name and address. Provider information should include the provider’s name, address, license number and WellChoice provider participation code.
3. Current procedure (CPT/HCPCS) and diagnosis codes (ICD-9) for services rendered
4. Itemized charges for each service performed.
5. The specific dates of service for services performed. This is particularly important if services provided on more than one day are included in one claim form.
6. If available, the WellChoice pre-authorization number for services requiring pre-approval according to the member’s contract. For physicians, this number should be listed in field number 23 of the HCFA 1500 claim form. For more information on the types of services requiring precertification:
   • Physicians – refer to the HMO and PPO Precertification Guide in the Medical Management Section of the WellChoice New Jersey Physician Sourcebook. To access the Sourcebook on line, please click on the following link: http://www.wellchoicenj.com/account_services/ physicians/sourcebook.shtml
   • Facilities – refer to the Notification Guidelines in the Medical Management Section of the WellChoice New Jersey Hospital/Facility Sourcebook. To access the Sourcebook on line, please click on the following link: http://www.wellchoicenj.com/account_services/facilities/index.shtml
7. If WellChoice coverage is secondary, you must first submit a claim to the primary insurance carrier. Once you have received the primary carrier’s Explanation of Benefits (EOB) regarding the claim, you should submit the claim with the relevant EOB to WellChoice for adjudication.

Reimbursement of all services is subject to the terms, conditions and limitations of the individual member’s coverage as specified in the governing benefit contract and/or certificate and clinical appropriateness standards as set forth in the WellChoice New Jersey Physician and Hospital/Facility SourceBook and related medical policies. Submission of all information listed above is subject to review by WellChoice as part of the claim payment adjudication process to confirm that medical necessity criteria have been met.

1. For claims reporting unlisted procedure codes – a complete description of the service performed.
2. For claims reporting durable medical equipment and supplies, including oxygen – the prescription and a clear description of the item(s) with itemized charges. When available, a picture of the item and any other explanatory material from the manufacturer.
3. For claims reporting prescription and injectable drugs – the dosage and National Drug Code (NDC) number.
4. For claims reporting the cost of a radiopharmaceutical – a copy of the invoice.
5. For claims reporting multiple surgical procedures – an operative report describing the exact procedures performed.
6. For claims reporting potentially cosmetic procedures, such as upper eyelid surgery – pre-operative photographs and documentation indicating that the procedure was medically necessary, i.e., was performed to improve and/or restore body function or to correct functional deformity resulting from disease, trauma, congenital or developmental anomalies, or previous therapeutic processes.
7. Experimental or Investigational services, is defined as technology that is:
   1. Not of proven benefit for the particular diagnosis or treatment of the covered person's particular condition; or
   2. Not generally recognized by the medical community as reflected in the published peer-reviewed medical literature as effective or appropriate for the particular diagnosis or treatment.
   We require copies of published peer-reviewed medical literature from recognized medical journals such as New England Journal of Medicine or Journal of American Medical Society documenting the efficacy of the procedure.
8. For claims reporting ongoing treatment (concurrent review) – medical records showing results from the treatment, such as disease regression and impact to the level of function. For claims reporting services defined in the medical policy as second-line or last resort therapy - documentation that the patient has not responded to the treatment of choice/first line therapy.
9. For claims reporting assistant surgeon services for procedures generally not warranting the services of an assistant as defined by CMS– the operative report documenting that some unusual complication or aspect of the procedure required a surgical assistant in addition to the operating room nurse or resident.
10. For claims reporting anesthesia services for procedures not warranting the general anesthesia (for example, a minor surgical procedure)–the patient’s applicable medical records which document the patient’s clinical need for the anesthesia service.
11. For claims reporting services requiring laboratory, radiology or machine testing prior to approval – a copy of the test results. For example, the results of blood gas studies should be submitted with the initial claim for oxygen, or x-rays with a claim demonstrating a fracture for bone growth stimulation services.
12. For claims reporting Home Health Care services – the provider’s treatment plan.

Reimbursement of all services is subject to the terms, conditions and limitations of the individual member’s coverage as specified in the governing benefit contract and/or certificate and clinical appropriateness standards as set forth in the WellChoice New Jersey Physician and Hospital/Facility SourceBook and related medical policies. Submission of all information listed above is subject to review by WellChoice as part of the claim payment adjudication process to confirm that medical necessity criteria have been met.