Clean Claim Requirements

Clean Claim Requirements (Cigna vendors)

Clean Claim Requirements were developed with the goal to process all claims at initial submission. Before Cigna can process a claim, it must be a “clean” or complete claim submission, which includes the following information, when applicable:

  • primary carrier explanation of benefits (EOB) when Cigna is the secondary payer
  • prescription for physical therapy
  • itemization of dates for physical therapy from facility
  • prosthesis invoice
  • trip notes for ambulance transport
  • standard Diagnostic Related Groupings (DRG) or Revenue codes (facility)
  • standard Health Care Procedure Coding System (HCPCS) code sets and modifiers
  • standard Current Procedural Terminology (CPT®) code sets and modifiers
  • standard International Classification of Diseases (ICD-10) codes, tenth revision
  • accurate entries for all the fields of information contained in the UB04 or CMS-1500 forms

The following modifiers do not require clinical records: CPT modifiers 26, 52, 63, or 90

Claims Requiring Clinical Documentation

Except as noted, Cigna routinely requires clinical documentation at the time a claim is submitted for the following categories of claims to be considered complete:

  • codes to which an assistant surgeon modifier (80, 81, or 82), assistant-at-surgery modifier (AS), or co-surgeon modifier (62) is attached that do not normally require surgical assistance or co-surgeons
  • an ‘unlisted code’ as defined in the Index of CPT under ‘Unlisted Services and Procedures’
  • a code that is not otherwise specified (NOS)
  • a code that is not otherwise classified (NOC)
  • procedures that are potentially cosmetic
  • procedures that may be experimental/investigational/unproven
  • procedures that are medically necessary for some indications and not for others
  • services performed in an unexpected place of service, such as office services performed in an outpatient surgery center
  • codes appended with a modifier indicating additional or unusual services (e.g., 22, 23, 24, 53, 59, or 66)
  • modifier 25 – Evaluation & Management (E/M) service codes that disallow with a CMS/NCCI Incidental Edit (also called Column 1/Column 2 Code Edits) designated by CMS as ‘1’
  • modifier 59 – Non-Evaluation & Management (E/M) service codes that disallow with a CMS/NCCI Mutually Exclusive Edit designated by CMS as ‘1’

The supporting documentation requirement is on selected code edits when modifier 25 or 59 is billed. It is not an across the board requirement for all uses of these modifiers.

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