Claim Documentation Requirements

HMSA routinely requires submission of clinical records before payment of claims when the claim includes any of the codes listed on these linked pages.

• Anesthesia Services – Claim Documentation Requirements
• Assisted Listening Devices – Claim Documentation Requirements
• Debridement – Claim Documentation Requirements
• Delivery/Birthing – Claim Documentation Requirements
• Durable Medical Equipment, Prosthetics, and Orthotics – Claim Documentation Requirements
• Evaluation and Management – Claim Documentation Requirements
• Medicine – Claim Documentation Requirements
• Miscellaneous Services – Claim Documentation Requirements
• Oral Surgery and Interdental Fixation Services – Claim Documentation Requirements
• Orthopedic Services – Claim Documentation Requirements
• Pathology and Lab – Claim Documentation Requirements
• QUEST Integration – Claims Requiring Attachments or Documentation
• QUEST Integration – Cosmetic Procedures – Claim Documentation Requirements
• Radiation Management – Claim Documentation Requirements
• Radiology Services – Claim Documentation Requirements
• Services Billed With Modifiers – Claim Documentation Requirements
• Surgery – Claim Documentation Requirements
• Unlisted and Miscellaneous Codes – Claim Documentation Requirements

In addition, HMSA may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is a reasonable basis for believing such investigation is warranted.

Revision History