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October 2014
Reminder: Payment decisions require supporting documentation
Claims are denied when there is not enough information available for us to make a payment decision. When this occurs, a new claim must be submitted with supporting documentation.
For more detailed descriptions of the Blue Cross Blue Shield of Michigan policies for these procedures, please check the benefit policy on web-DENIS. To access it, log in to web-DENIS, click on BCBSM Provider Publications and Resources, choose Benefit Policy for a Code and enter the procedure code.
Below is a list of some common services where payment is denied due to insufficient information, and what is needed to make a payment decision:
- If your patient has Medicare coverage, a copy of the Medicare voucher for the denied services must always be included with the new claim, along with other documentation as specified for the services below.
- All not-otherwise-classified codes, such as surgery, radiology, durable medical equipment, etc., should always be accompanied by a narrative description of the service.
Service |
What is needed |
Ambulance |
A copy of the ambulance record and the discharge or transfer summary from the referring hospital, indicating the medical necessity of the transfer |
Anesthesia |
A copy of the anesthesia report and operative notes when a not-otherwise-classified procedure code is reported. |
Drug code |
The national drug code and the appropriate quantity when reporting a drug procedure code on a professional claim |
Durable medical equipment |
A copy of the prescription, statement of medical necessity, invoice and complete description when an NOC procedure code is reported |
Emergency services |
A copy of the entire emergency room record and physician’s notes describing the patient’s condition and treatment provided when service was denied as a non-emergency condition |
Inpatient admissions |
A copy of the complete inpatient records |
Laboratory/Pathology |
A copy of the pathology report and complete description of the pathology procedure performed when reporting an NOC pathology or lab procedure code |
Medical care |
A copy of relevant clinic notes or evaluations that support the medical necessity of the treatment |
Medical supplies |
Clinical rationale that justifies exceeding the maximum supply quantity allowed. Limitations or restrictions to services need a statement of medical necessity. For example, if a reported quantity exceeds the maximum, documentation must include clinical rationale from the provider that justifies the exception.
A copy of the prescription, statement of medical necessity, invoice and complete description when reported with an NOC code |
Physical therapy and occupational therapy |
A copy of the physician’s order for therapy, initial evaluation, treatment notes from each visit, progress notes and summaries and, if applicable, the discharge summary when denial indicates supportive documentation is necessary for payment determination |
Pre-existing conditions |
A copy of the patient’s complete medical records with the medical records routing form to determine if the patient received treatment for the condition denied as pre-existing before the effective date of coverage |
Private duty nursing |
A copy of the physician’s certification, nurse’s license and photo ID, as well as hour-by-hour nursing or observation note |
Prosthetics and orthotics |
A copy of the prescription, statement of medical necessity, invoice and complete description when the item is reported with an NOC procedure code |
Radiology |
A copy of the radiology report and a complete description of the radiology procedure performed when reporting an unlisted or NOC radiology procedure code |
Skilled nursing facility and home health care |
A copy of medical records covering dates of service denied for SNF or HHC benefits |
Speech therapy |
A copy of physician’s order for therapy, initial evaluation, treatment notes from each visit, progress notes and summaries and, if applicable, the discharge summary when denial indicates supportive documentation is necessary for payment determination |
Surgery |
A copy of the operative report when an NOC procedure code is reported and a statement separate from the operative report that clarifies the actual surgical procedure reported under the NOC code. A copy of the operative report when the reported surgical procedure has been denied as ineligible for co-surgery, team surgery or technical surgical assistant benefits. |
For additional information about claims or payable services, see your online provider manual on web-DENIS. |
