CurrentAnthemPolicy N/A

Claims clinical information requests

Governs situations in which the payer may routinely require submission of clinical information for claims processing, affecting providers, members, and agents submitting claims to the payer.

Policy Summary

PayerAnthem

PolicyClaims clinical information requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide clinical information when requested for claims involving prior authorization, medical necessity, experimental determinations, or suspected inappropriate billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12+listed claim categories or situations where clinical information may be requested

includes pre-certification/prior authorizationexamples explicitly called out

includes audits, appeals, fraudadministrative actions triggering requests

includes underwriting, credentialing, QInon-claims operational activities listed

When Clinical Information May Be Requested

Situations prompting clinical information requests

Clinical information may be requested in the following situations (illustrative, not exhaustive):

ALL of the following

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 (e.g., Modifier 22)

Policy Summary

PayerAnthem

PolicyClaims clinical information requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide clinical information when requested for claims involving prior authorization, medical necessity, experimental determinations, or suspected inappropriate billing.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions — Prior Auth, Documentation, and Audits

Prior Authorization

Prior authorization / clinical information requests

Payer may routinely require submission of clinical information for claims involving pre‑certification/prior authorization, medical necessity or experimental/investigational determinations, and pharmaceuticals requiring prior authorization.

Documentation Required

Documentation to determine coverage

Payer may request clinical information for claims pending due to lack of precertification or prior authorization and for claims that cannot be adjudicated as a Covered Service without review of medical records.

Includes situations where the benefit determination cannot be made from the face of the claim (e.g., pre‑existing condition issues, emergency prudent layperson reviews, specific benefit exclusions).

Denial Risk

Denial risk / audit / fraud investigations

Payer may request clinical information for claims suspected of inappropriate or fraudulent billing and for claims that are the subject of audit, appeal, mediation, arbitration, or litigation.

Applies to claims under internal or external audit, including high‑dollar claims.
Also applies to claims involved in appeals, disputes, case management, underwriting reviews, recovery/subrogation, and other investigatory activities.

Defined Terms

Covered Service — definition entry

DefinitionCovered Service: a service for which the payer may determine benefits only after reviewing medical records when the face of the claim does not indicate that the service is covered (examples include pre-existing condition issues, emergency service–prudent layperson reviews, and specific benefit exclusions).

When clinical info may be requiredClaims for which the payer cannot determine from the face of the claim whether the item or service is a Covered Service, triggering review of medical records to make a benefit determination.

Related situationsIncludes situations such as pre-existing condition determinations, prudent layperson emergency service reviews, and assessment of specific benefit exclusions where coverage cannot be determined from the claim alone.

Purpose of requestTo enable the payer to make an accurate benefit determination when coverage status is not evident from claim data.

Pre-certification/prior authorization — definition entry

DefinitionPre-certification/prior authorization: a utilization review process (pre-certification, prior authorization, or pre-determination) for which the payer may routinely require submission of clinical information before or after payment.

Claims examplesClaims involving pre-certification/prior authorization or other utilization review, including claims pending for lack of precertification/prior authorization, claims involving medical necessity or experimental/investigative determinations, and pharmaceuticals requiring prior authorization.

When requestedPayer may request clinical information for claims pending due to lack of precertification/prior authorization or when utilization review determinations are needed to adjudicate the claim.

ScopeEncompasses pre-certification, prior authorization, pre-determination, and other forms of utilization review where clinical documentation supports the benefit or authorization decision.

unlisted codes	Claims involving unlisted codes may trigger requests for clinical information.
Modifier 22	Claims involving certain modifiers, including but not limited to Modifier 22, may routinely require clinical information.

OpenPayer

Claims clinical information requests

When Clinical Information May Be Requested

Codes That May Trigger Documentation Requests

Provider Actions — Prior Auth, Documentation, and Audits

Defined Terms