CurrentBlue Cross Blue Shield - MainePolicy C-22001

Claims Requiring Additional Documentation - Professional and Facility

Policy governing when Anthem Blue Cross and Blue Shield (including Anthem Health Plans of Maine) may request additional documentation to adjudicate professional and facility claims; applies to providers submitting claims for Anthem members. It explains types of claims that may require documentation and consequences if documentation is not provided.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyClaims Requiring Additional Documentation - Professional and Facility

Policy CodePolicy C-22001

Change TypeConsolidationadministrative review

Effective DateMar 23, 2022

Next Review Date

Key ActionSubmit additional documentation when requested to support adjudication of applicable claims to avoid denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

12/10/2024, 1 = Review approved: no changes.

03/23/2022, 1 = Initial approval and effective: Claims Requiring Additional Documentation-Professional C-16001 and Claims Requiring Additional Documentation-Facility C-16002 will be retired and combined into a new blended policy.

13+claim types listed

Standardcoding requirement

No exemptionspolicy exemptions

Review OKlast action

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyClaims Requiring Additional Documentation - Professional and Facility

Policy CodePolicy C-22001

Change TypeConsolidationadministrative review

Effective DateMar 23, 2022

Next Review Date

Key ActionSubmit additional documentation when requested to support adjudication of applicable claims to avoid 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.

Claims That May Require Additional Documentation

Claims requiring additional documentation

Applicable types of claims for which additional documentation may be required include, but are not limited to:

ALL of the following

ONE of
- 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
- Claims for services found to possibly conflict with medical necessity of covered benefits for covered persons
- 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
- Claims for beneficiaries where other health insurance is indicated with the claim submission
- 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
- Other documentation required by other entities such as CMS, 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 documentation is not provided following a request or notification, the Health Plan may deny the claim (as the provider failed to provide required prepayment documentation).

Denial or other recovery actions may follow per contractual obligations.

Provider Responsibilities and Consequences

Documentation Required

Submission of Additional Documentation

The Health Plan requires professional and facility providers to submit additional documentation for adjudication of applicable types of claims unless provider, state, federal contracts and/or mandates indicate otherwise. If the required documentation is not submitted, the claim may be denied.

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
Claims for services found to possibly conflict with medical necessity of covered benefits for covered persons
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
Claims for beneficiaries where other health insurance is indicated with the claim submission
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
Other documentation required by other entities such as CMS, 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

Denial Risk

Denial and Recovery Actions

The Health Plan may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations. If documentation is not provided following the request or notification, the Health Plan may take actions including denial and recovery/recoupment.

Deny the claim if the provider fails to provide required prepayment documentation
Recover and/or recoup monies previously paid on the claim if the provider fails to provide required documentation for post-payment review
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

Definitions and Referenced Policy Terms

Definitions — General reimbursement policy definitions referenced by this policy

Referenced definitionsGeneral Reimbursement Policy Definitions (see linked definitions section)

PurposeProvides standard terms used across reimbursement policies to ensure consistent interpretation and application

ScopeApplies to reimbursement and claims adjudication practices described in this policy (Claims Requiring Additional Documentation - Professional and Facility, Policy C-22001)

Use in adjudicationDefinitions support required documentation, coding expectations, and provider notification processes referenced throughout the policy

LocationDefinitions are located in the policy under the 'Definitions' heading and are referenced where applicable in coverage and provider action sections

OpenPayer

Claims Requiring Additional Documentation - Professional and Facility

Claims That May Require Additional Documentation

Coding Requirements

Provider Responsibilities and Consequences

Definitions and Referenced Policy Terms