Claim Submission Policy
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Governs Network Health/Care Continuum requirements for clean claim submissions, clinical documentation requests, timely filing, corrected claims, and related provider responsibilities across all lines of business.
No material clinical or coverage changes in this revision.
Claim Submission and Processing Criteria
Claim processing and submission criteria
Claims must include all required elements and meet form and submission rules to be processed; otherwise they will be denied or considered unclean.
Required Codes, Identifiers, and Clinical Trial Number Formats
| ICD | Standard International Classification of Diseases codes required on claims when applicable |
| CPT | Standard Current Procedural Terminology codes required |
| HCPCS | Healthcare Common Procedure Coding System codes required |
| NDC | National Drug Code required for miscellaneous drug codes |
| DRG/RUG | Diagnosis-related group and Resource Utilization Group codes when applicable |
Documentation Requests and Provider Responsibilities
Submit clinical records on request (pre- or post-payment)
Network Health may require submission of clinical records before or after payment to identify improper billings and detect suspicious claims. When requested, providers must submit the clinical documentation types listed (e.g., ambulance transport notes, anesthesia records, ER records, facility notes, MD notes, lab results, operative notes, physician office notes, radiology reports) for claims that fall into specified categories such as unlisted/NEC/NOS/NOC codes, potentially cosmetic or experimental procedures, services in unexpected places of service, codes with modifiers indicating additional or unusual services, or codes with assistant/co‑surgeon modifiers that are not normally required.
- Requested documentation may be required before or after claim payment for fraud detection and billing validation.
- Types of documentation that may be requested: ambulance transport notes; anesthesia records; ER records; facility notes; MD notes; laboratory results; operative notes; physician office notes; radiology interpretation and report.
- Claims triggering requests include unlisted, NEC/NOS/NOC codes; potentially cosmetic, experimental/investigational/unproven procedures; services in unexpected places of service; codes with modifiers for additional/unusual services; assistant/co‑surgeon usage where not normally required.
Key Definitions
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