Clean Claim Requirements

At Prevea360 Health Plan, our goal is to process all claims in a timely fashion. Before we can process a claim, it must be "clean." The Clean Claim Requirements include the following information, when applicable:

  • primary carrier Explanation of Benefits (EOB) when Prevea360 Health Plan is the secondary payer
  • standard Diagnostic Related Groupings (DRG) or Revenue codes (facility)
  • standard Health Care Procedure Coding System (HCPCS) code sets and modifiers
  • standard Current ProceduralTerminology (CPT) code sets and modifiers
  • standard International Classification of Diseases (ICD-9) codes, 9th revision
  • accurate entries for all the fields of information contained in the UB-92 or CMS-1500 forms

Except as noted, we routinely require clinical documentation or additional internal review for the following categories of claims to be considered clean:

  • codes appended with a modifier indicating additional or unusual services (e.g., 22, 23, 24, 53, 59, or 66)
    • Exception: The following modifiers do not require clinical records
      • Any HCPCS modifiers
      • CPT modifiers 25, 26, 52, 63, or 90
  • 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

Beyond the above categories, Prevea360 Health Plan 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 reasonable basis for believing such investigation is warranted.

This policy is not designed to limit Prevea360 Health Plan’s right to require submission of medical records for precertification purposes.