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Claims requiring submission of clinical information

AmeriHealth may require the submission of clinical information before or after the processing of a claim for services rendered to members. Clinical information is required to process claims that include pre-existing conditions and issues pertaining to mental health, psychiatric and substance abuse, organ transplants, cosmetic and reconstructive surgery, and/or a number of other limited categories. These categories include:

  • Appeals for procedures denied as possibly cosmetic
  • Appeals of claims disputing multiple-procedure payment reduction
  • Appeals of claims requesting additional reimbursement for an unusual surgical procedure
  • Appeals of claims requesting reimbursement in pre-op or post-op period
  • Appeals of claims for medical necessity
  • Appeals of claims for experimental or investigative services
  • Appeals of claims for pre-existing conditions
  • Appeals of claims disputing claim coding edits
  • Audit/investigation requests from our Corporate and Financial Investigations Department
  • Behavioral health claims for which required authorization was not obtained
  • Behavioral health emergency room services more than $500
  • Claims for procedures that are possibly cosmetic
  • Claims submitted for assistant surgery
  • Claims submitted for team surgery
  • Claims submitted for co-surgery
  • Claims submitted with procedure codes that are unlisted or not otherwise classified
  • Claims submitted with the Modifier 22
  • Claims that require a review for possible pre-existing conditions
  • Emergency room claims submitted with a nonemergent diagnosis
  • Inpatient and outpatient post-service authorization requests

Notwithstanding the above, AmeriHealth may continue to require submission of clinical information and other additional information in connection with its review of specific claims. The categories listed above are not intended, nor shall they be construed, to alter or limit our ability to request clinical information in connection with adjudication of claims.

AmeriHealth will contact you if clinical information is required for claims processing.