Claim Submission Policy
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Governs Network Health (Care Continuum) requirements for clean claim submissions, necessary clinical documentation, timely filing limits, corrected claim procedures, and related billing elements for all lines of business and providers.
No material clinical or coverage changes in this revision.
Claims Processing Requirements
Claims processing criteria
Claims will be processed only when they meet clean-claim criteria and form/submission rules. Covered when ALL of the following are met:
Timely filing
- Outpatient and inpatient claims for commercial and participating Medicare providers: submit within 90 days of date of service unless provider contract specifies otherwise.
- Medicare non‑participating providers: submit outpatient and inpatient claims within 365 days of date of service.
- When Network Health is the secondary payer: submit within 90 days of the primary payer's payment (or as specified in the provider contract).
Coding, Timely Filing, and Corrected Claims
| ICD | Standard International Classification of Diseases codes required on claims |
| CPT | Standard Current Procedural Terminology (CPT) code sets |
| HCPCS | Standard Healthcare Common Procedure Coding System (HCPCS) code sets |
| NDC | National Drug Code required for miscellaneous drug codes |
Documentation Requests and Provider Responsibilities
Clinical documentation requests (provide requested records upon request)
Network Health may routinely request clinical documentation for claims that involve unlisted/NEC/NOS/NOC codes; procedures that are potentially cosmetic, experimental/investigational/unproven, or medically necessary for some indications but not others; services performed in an unexpected place of service; codes with modifiers indicating additional or unusual services; and codes with assistant or co‑surgeon modifiers when not normally required. Types of documentation that may be requested include ambulance transport notes, anesthesia records, ER records, facility notes, MD notes, lab results, operative notes, physician office notes, and radiology reports. Network Health may also require medical records before or after payment to identify improper or suspicious billings. This guideline does not limit Network Health’s right to require records for precertification purposes.
- Unlisted services (CPT/HCPCS unlisted codes), NEC, NOS, NOC
- Potentially cosmetic procedures
- Experimental/investigational/unproven procedures
- Procedures medically necessary for some indications but not others
- Services in unexpected place of service (e.g., office services in outpatient surgery center)
- Codes appended with modifiers indicating additional/unusual services
- Codes with assistant or co‑surgeon modifiers not normally required
- Requested documentation types: ambulance transport notes, anesthesia records, ER records, facility notes, MD notes, lab results, operative notes, physician office notes, radiology interpretation/reports
- Records may be requested before or after payment to identify improper or suspicious billing; does not limit precertification record requests
Key Definitions
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