CurrentBlue Cross Blue Shield - NevadaPolicy G-06031

Claims Requiring Additional Documentation

Defines when Anthem Medicare Advantage (Blue Cross Blue Shield - Nevada) may request additional documentation for claim adjudication and the potential consequences for providers if documentation is not supplied. Applies to professional and facility providers submitting claims to Anthem Medicare Advantage.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyClaims Requiring Additional Documentation

Policy CodePolicy G-06031

Change TypeNo material changes

Effective DateJun 2, 2022

Next Review Date

Key ActionProviders must submit additional documentation when requested for adjudication of applicable claim types to avoid claim denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

participatingprovider applicability

multipleclaim categories

denied/recoupedfinancial outcome risk

CMSregulatory cite

Claims Requiring Additional Documentation

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Claims requiring additional documentation

Anthem may request additional documentation for the following types of claims:

ALL of the following

Claims for services requiring clinical review.
Claims with unlisted or miscellaneous codes.
Claims for services found to possibly conflict with covered benefits for covered persons after validity review of the member's medical records.
Claims requesting an extension of benefits.
Claims for services found to possibly conflict with medical necessity of covered benefits for covered persons.
Claims being reviewed for potential fraud, abuse, or demonstrated patterns of billing/coding inconsistent with peer benchmarks.
Claims for services that require an itemized bill.
Claims for services that require an invoice.
Claims for beneficiaries with Other Health Insurance (OHI).
Claims requiring a certificate of medical necessity.
Claims requiring documentation of the receipt of an informed consent form.
Appealed claims where supporting documentation may be necessary for determination of payment.
Upon request: claims for Durable Medical Equipment; Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health and Rehabilitation Therapies.
Other documentation required by the Centers for Medicare & Medicaid Services (CMS), and state or federal regulation.

Note: Itemized bills must be submitted with the appropriate revenue code for each individual charge when requested.

ANY of the following

If documentation is not provided following the request or notification, Anthem Medicare Advantage may deny the claim as the provider failed to provide required prepayment documentation.
If documentation is not provided following the request or notification, Anthem Medicare Advantage may recover and/or recoup monies previously paid on the claim as the provider failed to provide required documentation for post payment review.
Anthem Medicare Advantage is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation.

Standard Correct Coding applies.

Requests for and Requirements Around Additional Documentation

Denial Risk

Submit requested documentation or risk denial/recoupment

Anthem Medicare Advantage requires professional and facility providers to submit additional documentation for adjudication of applicable claim types; if required documentation is not submitted, the claim may be denied. Anthem may also recover/recoup monies previously paid when documentation is not provided for post‑payment review, and is not liable for interest or penalties when payment is denied or recouped due to provider failure to submit required documentation.

Providers must supply documentation when requested for claims such as those requiring clinical review, with unlisted/miscellaneous codes, under review for fraud/abuse, appealed claims needing supporting records, DMEPOS/Home Health/Rehabilitation therapy claims upon request, and other CMS/state‑required documentation.
Failure to provide requested documentation may result in claim denial or recovery/recoupment of previously paid amounts.

Billing Rule

Provide itemized bills with appropriate revenue codes

When Anthem requests an itemized bill, providers must submit it with the appropriate revenue code for each individual charge.

Itemized bills are required for claim types that specifically request them (e.g., services that require an itemized bill or invoice).
Each line must include the appropriate revenue code corresponding to the individual charge.

Definitions

Additional documentation

TermAdditional documentation

DefinitionDocumentation or records beyond the claim form that Anthem Medicare Advantage may request to adjudicate a claim, such as itemized bills, invoices, medical records, certificates of medical necessity, informed consent, or other supporting materials.

When requestedFor claims requiring clinical review; claims with unlisted or miscellaneous codes; claims under review for medical necessity, potential fraud/abuse, atypical billing patterns, or appealed claims where supporting documentation is necessary.

Billing detailsItemized bills must include the appropriate revenue code for each individual charge when requested; invoices or itemized statements may also be required for facility or DMEPOS claims.

Consequences of non‑submissionIf required documentation is not submitted, Anthem Medicare Advantage may deny the claim, recover/recoup payment, reject the claim, or adjust reimbursement based on available information.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyClaims Requiring Additional Documentation

Policy CodePolicy G-06031

Change TypeNo material changes

Effective DateJun 2, 2022

Next Review Date

Key ActionProviders must submit additional documentation when requested for adjudication of applicable claim types to avoid claim denial or recoupment.

SourceLink

On This Page

CPT	Standard industry CPT coding expected on claim submissions; billed codes must be supported by medical records.
HCPCS	HCPCS codes expected where applicable.
Revenue	Appropriate revenue codes required on itemized bills.

OpenPayer

Claims Requiring Additional Documentation

Claims Requiring Additional Documentation

Expected Coding Systems

Requests for and Requirements Around Additional Documentation

Definitions