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Routinely Required Clinical Information
The following is a list of claims categories where we may routinely require submission of Clinical Information before or after payment of a claim:
- Claims involving pre-certification/prior authorization/pre-determination (or some other form of utilization review including but not limited to:
- Claims pending for lack of precertification or prior authorization
- Claims involving Medical Necessity or Experimental/ Investigative determinations
- Claims for pharmaceuticals requiring prior authorization.
- Claims involving certain modifiers, including but not limited to Modifier 22.
- Claims involving unlisted codes.
- Claims for which we cannot determine from the face of the claim whether it involves a Covered Service thus the benefit determination can’t be made without reviewing medical records (including but not limited to pre-existing condition issues, emergency service-prudent layperson reviews, specific benefit exclusions).
- Claims that we have reason to believe involve inappropriate (including fraudulent) billing
- Claims that are the subject of an audit (internal or external) including high dollar claims.
- Claims for individuals involved in case management or disease management.
- Claims that have been appealed (or that are otherwise the subject of a dispute, including claims being mediated, arbitrated, or litigated)
- Other situations in which clinical information might routinely be requested:
- Other situations in which clinical information might routinely be requested:
- Requests relating to underwriting (including but not limited to member or physician misrepresentation/fraud reviews and stop loss coverage issues);
- Accreditation activities;
- Quality improvement/assurance activities;
- Credentialing;
- Coordination of benefits; and
- Recovery/subrogation.
Examples provided in each category are for illustrative purposes only and are not meant to represent an exhaustive list within the category.
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