CurrentAnthemPolicy G-06031

Claims Requiring Additional Documentation

Defines when Anthem (Wisconsin) requires providers to submit additional documentation for claim adjudication and identifies types of claims that may trigger documentation requests; applies to professional and facility providers for Anthem Blue Cross and Blue Shield BadgerCare Plus and Medicaid SSI programs in Wisconsin.

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 when requested for adjudication of applicable claims; failure to provide may result in denial, recoupment, or adjustment of claim payment.

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 claim types

WIState scope

05/06/2025Effective

AllProvider applicability

Claims That Require Additional Documentation

Documentation requirements for applicable claim types

The health plan requires additional documentation for adjudication of applicable claim types; if documentation is not submitted, claims may be denied or recouped.

Providers must submit additional documentation when requested for applicable claims; failure to provide required documentation may result in denial, recoupment, or adjustment of claim payment.

Applicable types of claims

Claims with unlisted or miscellaneous codes.
Claims for services requiring clinical review.
Claims for services found to possibly conflict with covered benefits after 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 when requested for adjudication of applicable claims; failure to provide may result in denial, recoupment, or adjustment of claim payment.

SourceLink

On This Page

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Claims for services found to possibly conflict with medical necessity of covered benefits.

Claims requesting an extension of benefits.

Claims being reviewed for potential fraud, abuse, or demonstrated patterns of billing/coding inconsistent with peer benchmarks.

Claims for services that require an invoice.

Claims for services that require an itemized bill (itemized bills must include the appropriate revenue code for each individual charge).

Claims for beneficiaries with Other Health Insurance (OHI).

Claims requiring documentation of the receipt of an informed consent form.

Claims requiring a certificate of medical necessity.

Appealed claims where supporting documentation may be necessary for determination of payment.

Claims where other documentation is required by CMS and/or state or federal regulation.

Upon request, claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health and Rehabilitation Therapies.

Claims being reviewed to validate the correct diagnosis related group (DRG) assignment/payment.

Claims being reviewed to validate items and services billed are documented in the medical record for hospital bill audits or reviews.

If requested documentation is not provided, the plan may deny the claim (prepayment) or recover/recoup monies previously paid (post-payment); the plan is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required documentation.

Coding and Billing Documentation Requirements

Unlisted/miscellaneous codesmixedCovered

Unlisted/Miscellaneous

Claims with unlisted or miscellaneous codes require additional documentation to support services billed.

Itemized bill requirement

Itemized bill requirementItemized bills must be submitted with the appropriate revenue code for each individual charge.

Invoice requirementClaims for services that require an invoice must include the requested invoice documentation when requested by the plan.

Revenue code specificityEach individual charge on an itemized bill must show the appropriate revenue code to support adjudication and payment.

Provider Documentation Obligations and Consequences

Denial Risk

Provide requested documentation or risk denial/recoupment

Submit additional documentation when requested for adjudication of applicable claims. Failure to provide required documentation may result in denial, recovery/recoupment of previously paid amounts, or adjustment of claim payment; the plan is not liable for interest or penalties when payment is denied or recouped for failure to submit required documentation.

If documentation is not submitted after request, the claim may be denied for failure to provide required prepayment documentation.
For post-payment review, the plan may recover and/or recoup monies previously paid if required documentation is not provided.

Documentation Required

Supply DMEPOS/Home Health/Rehab documentation on request

Upon request, submit supporting documentation for claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Home Health, and Rehabilitation Therapies to support adjudication.

Include itemized bills and invoices when requested; itemized bills must include the appropriate revenue code for each individual charge.

Definitions: Additional Documentation

Documentation submitted by provider or facility to support claim adjudication

Definition of additional documentationDocumentation submitted by provider or facility to support claim adjudication, which may include invoices, itemized bills, certificates of medical necessity, informed consent forms, medical records, or other materials requested by the plan.

Examples of supporting documentsInvoices, itemized bills, certificates of medical necessity, informed consent forms, and medical records may be requested to substantiate billed services.

When documentation is requestedThe health plan may request additional documentation for applicable claim types (e.g., unlisted codes, clinical review, fraud review, OHI situations, appealed claims, DMEPOS, Home Health, Rehab therapies).

Consequences of non‑submissionIf requested documentation is not provided, the plan may deny the claim or recover/recoup previously paid amounts; the plan is not liable for interest or penalties related to such denials or recoupments.