CurrentAnthemPolicy N/A

Clinical Information that may be Required for Claim Adjudication

This document lists categories of claims for which Anthem Blue Cross and Blue Shield may routinely require submission of clinical information before or after payment; it applies to claims processing and related administrative functions.

Policy Summary

PayerAnthem

PolicyClinical Information that may be Required for Claim Adjudication

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit clinical information when claims involve pre-certification/prior authorization, pharmaceuticals requiring prior authorization, or other utilization review processes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11+claim categories listed where clinical information may be required

illustrative onlyexamples not exhaustive

pre/postapplies pre- and post-payment

When Clinical Information May Be Requested

Situations prompting clinical information requests

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

ALL of the following

Utilization review and authorization
- Claims involving pre-certification, prior authorization, pre-determination, or other utilization review processes.
- Claims pending for lack of precertification or prior authorization.
- Claims involving medical necessity or experimental/investigational determinations.
- Claims for pharmaceuticals requiring prior authorization.

Policy Summary

PayerAnthem

PolicyClinical Information that may be Required for Claim Adjudication

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit clinical information when claims involve pre-certification/prior authorization, pharmaceuticals requiring prior authorization, or other utilization review processes.

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 Responsibilities and Action Items

Prior Authorization

Prior Authorization and Utilization Review — Clinical Information May Be Required

Submit clinical documentation for claims that involve pre-certification, prior authorization, pre-determination, or other utilization review processes. This includes claims pending because of lack of precertification or prior authorization, and claims for pharmaceuticals that require prior authorization.

Claims pending for lack of precertification/prior authorization
Claims for pharmaceuticals requiring prior authorization
Other utilization review processes (pre-determination, utilization review)

Documentation Required

Medical Necessity and Investigational Determinations — Provide Medical Records/Clinical Documentation

Provide complete medical records and clinical documentation when a claim is under review for medical necessity or is being evaluated as investigational/experimental. This includes claims where the face of the claim does not establish coverage, claims involving Medical Necessity or Experimental/Investigational determinations, and any claim subject to audit, appeal, or suspected inappropriate billing.

Claims involving Medical Necessity determinations
Claims involving Experimental/Investigational determinations
Claims where coverage cannot be determined from the claim alone (e.g., pre-existing condition reviews, emergency prudent layperson reviews)
Claims subject to audit, appeal, mediation, arbitration, or litigation
Claims with suspected inappropriate or fraudulent billing

Definitions

Clinical Information — definition entry

DefinitionClinical Information: medical records, documentation, or other clinical data submitted to Anthem Blue Cross and Blue Shield to determine coverage, medical necessity, investigate potential inappropriate or fraudulent billing, support audits, or otherwise adjudicate claims.

When requiredMay be requested before or after payment for categories including pre-certification/prior authorization matters, claims with certain modifiers (e.g., Modifier 22), unlisted procedure codes, claims where coverage cannot be determined from the claim alone, suspected inappropriate/fraudulent billing, audit targets, case- or disease-management cases, appealed or disputed claims, and other administrative activities (underwriting, accreditation, quality improvement, credentialing, coordination of benefits, recovery/subrogation).

ScopeRequests apply to a broad range of claim categories; examples in the list are illustrative and not exhaustive.

PurposeTo enable benefit determinations, medical necessity and investigational determinations, prior-authorization decisions, audit and recovery activities, and other administrative adjudication functions.

Utilization review — definition entry

DefinitionUtilization review: processes such as pre-certification, prior authorization, and pre-determination (or other forms of utilization review) used by Anthem to evaluate claims and determine coverage or payment.

Examples of triggersClaims pending for lack of precertification/prior authorization; claims involving medical necessity or experimental/investigative determinations; pharmaceuticals requiring prior authorization.

How it affects providersProviders may be asked to submit clinical information when claims involve utilization review to support benefit, medical necessity, or authorization determinations.

TimingRequests may occur before or after claim payment depending on the situation (pre- or post-payment utilization review).

Modifier 22	Claims involving certain modifiers may require clinical information (Modifier 22 cited as example).
Unlisted procedure codes	Claims involving unlisted codes may require submission of supporting clinical documentation.

OpenPayer

Clinical Information that may be Required for Claim Adjudication

When Clinical Information May Be Requested

Modifiers, Unlisted Codes, and Related Coding Rules

Provider Responsibilities and Action Items

Definitions