CurrentAnthemPolicy G-06031

Claims Requiring Additional Documentation

Defines when Anthem requires providers to submit additional documentation to adjudicate professional and facility claims for California Medi‑Cal Managed Care members; affects participating and non‑participating providers submitting claims in scope.

Policy Summary

PayerAnthem

PolicyClaims Requiring Additional Documentation

Policy CodePolicy G-06031

Change TypeAdded applicable claim types

Effective Date05/06/2025

Next Review Date

Key ActionSubmit additional documentation upon request for adjudication of applicable claim types; failure to provide may result in denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

Added applicable claim types: claims being reviewed to validate the correct diagnosis related group (DRG) assignment/payment and claims being reviewed to validate items and services billed are documented in the medical record for hospital bill audits or reviews.

15+listed applicable claim types that may require additional documentation

05/06/2025last approval/effective date

Californiajurisdiction explicitly named

Applies to both participating and non‑participating providersprovider applicability

When Additional Documentation Is Required

Requirement to Provide Documentation

The health plan requires submission of additional documentation for adjudication of applicable claim types; if not submitted, the claim may be denied or previously paid amounts recouped.

The health plan requires professional and facility providers to submit additional documentation for adjudication of applicable types of claims unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Applicable types of claims include

Claims with unlisted or miscellaneous codes
Claims for services requiring clinical review
Claims for services found to possibly conflict with covered benefits for covered persons after validity review of the member's medical records

Policy Summary

PayerAnthem

PolicyClaims Requiring Additional Documentation

Policy CodePolicy G-06031

Change TypeAdded applicable claim types

Effective Date05/06/2025

Next Review Date

Key ActionSubmit additional documentation upon request for adjudication of applicable claim types; failure to provide may result in denial or recoupment.

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 Submission Requirements

Documentation Required

Documentation submission required upon request; noncompliance may lead to denial/recoupment

Submit additional documentation for adjudication when requested. If the required documentation is not provided after the plan's request or notification, the claim may be denied or previously paid amounts may be recovered/recouped.

Applicable claim types that may trigger a request include unlisted/miscellaneous codes, services requiring clinical review, claims under fraud/abuse review, DMEPOS/Home Health/Rehab therapies upon request, DRG validation reviews, hospital bill audits, appealed claims, claims requiring invoices/itemized bills, OHI cases, claims requiring certificates of medical necessity or informed consent, and other CMS/state-required documentation.
The health plan is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation.

Billing Rule

Itemized bills must include the appropriate revenue code per charge

When an itemized bill is required, it must be submitted with the appropriate revenue code for each individual charge.

Note explicitly stated in policy: "Itemized bills must be submitted with the appropriate revenue code for each individual charge."

Key Definitions

inv-05: Additional documentation — definition and examples of materials that qualify as additional documentation.

DefinitionAdditional documentation: any provider or facility records, itemized bills, invoices, certificates of medical necessity, informed consent forms, or other materials requested to support adjudication of a claim.

ExamplesItemized bills or invoices that include the appropriate revenue code for each individual charge.

Clinical recordsProvider or facility medical records and office notes used to substantiate services billed (e.g., for clinical review, DRG validation, or hospital bill audits).

DMEPOS / Home health materialsDurable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health and Rehabilitation Therapy documentation when requested.

Regulatory or appeal materialsDocumentation required by CMS, state or federal regulation, or supporting documentation for appealed claims.

inv-06: Applicable claim types — list of claim categories that may trigger requests for additional documentation.

Unlisted or miscellaneous codesClaims with unlisted or miscellaneous codes may trigger requests for additional documentation.

Services requiring clinical review or medical necessity validationClaims for services requiring clinical review or found to possibly conflict with covered benefits or medical necessity.

Itemized/invoice-required claimsClaims that require an itemized bill or invoice (must include appropriate revenue codes) may trigger documentation requests.

Potential fraud/aberrant billingClaims under review for potential fraud, abuse, or demonstrated patterns of billing/coding inconsistent with peer benchmarks.

OHI, DMEPOS, DRG validation, appealsClaims for beneficiaries with Other Health Insurance (OHI); DMEPOS and Home Health/Rehab claims upon request; claims being reviewed to validate DRG assignment/payment; appealed claims needing supporting documentation.

OpenPayer

Claims Requiring Additional Documentation

When Additional Documentation Is Required

Coding and Billing Codes

Provider Responsibilities and Submission Requirements

Key Definitions