Currentcare_continuumPolicy n05659

Claim Submission Policy

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Defines Network Health/Care Continuum requirements for clean claim submissions, corrected claims, clinical documentation requests, and timely filing for providers submitting institutional and professional claims.

Policy Summary

Payercare_continuum

PolicyClaim Submission Policy

Policy CodePolicy n05659

Change TypeNo material changes

Effective DateFeb 1, 2020

Last ReviewJun 20, 2023

Next Review Date

Key ActionSubmit claims as a clean claim with all required elements or expect potential denial and requests for clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystimely filing limit for outpatient and inpatient claims

120 daystimeframe to submit corrected claims after original remittance

UB04 / HCFA-1500required claim form types

Multipleenumerated minimum claim elements for a clean claim

Claim submission and processing rules

Claim submission and processing criteria

Requirements and operational rules providers must follow for claim acceptance, processing, and potential denials.

Claims must be submitted on UB04-1450 (Institutional) or HCFA-1500 (Professional) claim forms.

ALL of the following

Minimum required elements include: Network Health ID, patient name, date of birth, subscriber name/address, patient signature or indication of signature on file, ICD codes, dates of service, place of service or bill type, CPT codes, HCPCS codes, revenue codes (facility), modifiers, DRG, RUG (when applicable), individual charges, units of service, provider NPIs, billing provider NPI, provider TIN, taxonomy code (Medicare only), facility/provider and billing provider contact info, accident state, provider signature, primary carrier EOB when Network Health is secondary, explanations for miscellaneous circumstances, NDC for miscellaneous drug codes, and Clinical Trial Number.

Clinical trial registry numbers must be placed in the specified fields: UB04 value code D4 (8-digit numeric), HCFA paper Field 19 prefixed with 'CT', and electronic 837P REF02 without 'CT' (REF01=P4).

Miscellaneous drug codes require the National Drug Code (NDC) on the corresponding claim line.

Outpatient claims must be submitted within 90 days of the date of service; inpatient claims within 90 days from discharge. When Network Health is secondary, submit within 90 days of the primary payer remittance or as specified in the provider contract.

A corrected claim is any claim with changes to the original submission (e.g., charges, procedure/diagnosis codes, dates of service) and must be submitted within 120 days of the original remittance. Corrected EDI claims must include the entire original claim and indicate what is being corrected; HCFA requires resubmission code '7' in box 22 with original claim number; UB04 requires the appropriate corrected bill type (XX5, XX7, XX8).

Documentation requests (one or more may apply)

Unlisted codes, NEC/NOS/NOC codes, procedures potentially cosmetic, experimental/investigational/unproven, procedures medically necessary for some indications but not others.
Services performed in an unexpected place of service or codes appended with modifiers indicating additional or unusual services, or codes with assistant/co-surgeon modifiers that do not normally require them.
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, radiology reports; Network Health may require records before or after payment to identify improper billings.

If a claim contains required billing information but needs additional information to make a benefit determination, Network Health will notify the provider (via Remittance Advice) and patient (via EOB) that additional information is necessary.

Claims missing required information will be denied with the appropriate CARC indicating additional information is required; timely filing failures will deny with CARC 29. Providers cannot bill members for claims denied due to provider billing errors or missing provider information; providers may bill members only when required information is needed from the patient.

Network Health will only accept written claims submitted in English. If a claim is rejected for improper EDI submission, the provider must resubmit within the filing limits; EDI rejections are available on the provider portal.

Codes, coding rules, and deadlines

Codes requiring documentationCPT | HCPCS | ModifierCovered

unlisted / NEC / NOS / NOC	Unlisted or not elsewhere classified/specified codes may trigger documentation requests
modifiers	Codes appended with modifiers indicating additional or unusual services may require supporting documentation

Drug codingNDCCovered

NDC	National Drug Code required on claim lines for miscellaneous drug codes

Claim submission deadline (outpatient/inpatient) — 90 days

Outpatient claim timely filingOutpatient claims must be submitted within 90 days of the date of service.

Inpatient claim timely filingInpatient claims must be submitted within 90 days from discharge date.

Secondary payer timingWhen Network Health is secondary payer, submit within 90 days of the primary payer remittance or per provider contract.

Corrected claim submission deadline — 120 days from original remittance

Corrected claim deadlineCorrected claims must be submitted within 120 days of the original claim remittance advice.

EDI corrected claim requirementProviders must submit the entire original claim electronically/EDI when submitting a corrected claim; Network Health will not accept only the corrected lines.

Resubmission/bill type guidanceHCFA resubmissions require resubmission code '7' in box 22 with the original claim number; UB04 corrected claims require an appropriate XX5/XX7/XX8 bill type to indicate correction.

Documentation requests and provider requirements

Documentation Required

Requests for clinical documentation and additional information

Network Health will routinely request clinical documentation for certain claim categories and may require records before or after payment to identify improper or suspicious billing. Examples of categories triggering requests include unlisted codes, NEC/NOS/NOC codes, potentially cosmetic or experimental procedures, services in unexpected places of service, codes with modifiers indicating additional/unusual services, and codes with assistant/co‑surgeon modifiers when not typically 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.

Requests commonly triggered by: unlisted codes; NEC/NOS/NOC codes; cosmetic or experimental procedures; services in unexpected place of service; modifier‑appended codes; assistant/co‑surgeon modifier codes.
May require records before or after payment to detect improper or suspicious billing.
Acceptable documentation examples: ambulance transport notes; anesthesia records; ER records; facility notes; MD notes; lab results; operative notes; physician office notes; radiology interpretation/reports.

Key definitions

Corrected claim definition

DefinitionA corrected claim is any claim that has a change to the original claim submission (for example, changes or corrections to charges, procedure or diagnosis codes, dates of service, etc.).

Submission requirementProviders must indicate what is being corrected (use remark/notes field for EDI) or the claim may deny as a duplicate.

Content of corrected EDI claimsNetwork Health requires submission of the entire original claim electronically/EDI when submitting a corrected claim; partial-line corrected submissions are not accepted.

Clean claim definition

DefinitionA clean claim is a claim that includes all required claim elements and can be processed on initial submission.

Consequence of unclean claimIf a claim lacks required minimum elements it will be considered unclean and denied with the appropriate CARC indicating additional information is required.

Provider liability until clean claimUntil Network Health receives a clean claim, the provider is liable for charges and cannot bill the patient (except when required billing information is needed from the patient).

Policy Summary

Payercare_continuum

PolicyClaim Submission Policy

Policy CodePolicy n05659

Change TypeNo material changes

Effective DateFeb 1, 2020

Last ReviewJun 20, 2023

Next Review Date

Key ActionSubmit claims as a clean claim with all required elements or expect potential denial and requests for clinical documentation.

SourceLink

On This Page

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Claim Submission Policy

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Claim submission and processing rules

Claim submission and processing criteria

Requirements and operational rules providers must follow for claim acceptance, processing, and potential denials.

Claims must be submitted on UB04-1450 (Institutional) or HCFA-1500 (Professional) claim forms.

ALL of the following

Minimum required elements include: Network Health ID, patient name, date of birth, subscriber name/address, patient signature or indication of signature on file, ICD codes, dates of service, place of service or bill type, CPT codes, HCPCS codes, revenue codes (facility), modifiers, DRG, RUG (when applicable), individual charges, units of service, provider NPIs, billing provider NPI, provider TIN, taxonomy code (Medicare only), facility/provider and billing provider contact info, accident state, provider signature, primary carrier EOB when Network Health is secondary, explanations for miscellaneous circumstances, NDC for miscellaneous drug codes, and Clinical Trial Number.

Miscellaneous drug codes require the National Drug Code (NDC) on the corresponding claim line.

Documentation requests (one or more may apply)

Unlisted codes, NEC/NOS/NOC codes, procedures potentially cosmetic, experimental/investigational/unproven, procedures medically necessary for some indications but not others.
Services performed in an unexpected place of service or codes appended with modifiers indicating additional or unusual services, or codes with assistant/co-surgeon modifiers that do not normally require them.
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, radiology reports; Network Health may require records before or after payment to identify improper billings.

Codes, coding rules, and deadlines

Codes requiring documentationCPT | HCPCS | ModifierCovered

unlisted / NEC / NOS / NOC	Unlisted or not elsewhere classified/specified codes may trigger documentation requests
modifiers	Codes appended with modifiers indicating additional or unusual services may require supporting documentation

Drug codingNDCCovered

NDC	National Drug Code required on claim lines for miscellaneous drug codes

Claim submission deadline (outpatient/inpatient) — 90 days

Outpatient claim timely filingOutpatient claims must be submitted within 90 days of the date of service.

Inpatient claim timely filingInpatient claims must be submitted within 90 days from discharge date.

Secondary payer timingWhen Network Health is secondary payer, submit within 90 days of the primary payer remittance or per provider contract.

Corrected claim submission deadline — 120 days from original remittance

Corrected claim deadlineCorrected claims must be submitted within 120 days of the original claim remittance advice.

EDI corrected claim requirementProviders must submit the entire original claim electronically/EDI when submitting a corrected claim; Network Health will not accept only the corrected lines.

Documentation requests and provider requirements

Documentation Required

Requests for clinical documentation and additional information

Requests commonly triggered by: unlisted codes; NEC/NOS/NOC codes; cosmetic or experimental procedures; services in unexpected place of service; modifier‑appended codes; assistant/co‑surgeon modifier codes.
May require records before or after payment to detect improper or suspicious billing.
Acceptable documentation examples: ambulance transport notes; anesthesia records; ER records; facility notes; MD notes; lab results; operative notes; physician office notes; radiology interpretation/reports.

Key definitions

Corrected claim definition

DefinitionA corrected claim is any claim that has a change to the original claim submission (for example, changes or corrections to charges, procedure or diagnosis codes, dates of service, etc.).

Submission requirementProviders must indicate what is being corrected (use remark/notes field for EDI) or the claim may deny as a duplicate.

Clean claim definition

DefinitionA clean claim is a claim that includes all required claim elements and can be processed on initial submission.

Consequence of unclean claimIf a claim lacks required minimum elements it will be considered unclean and denied with the appropriate CARC indicating additional information is required.