Reminder: Supporting documentation required for certain claim types

Specific documentation should be attached to the Medical Record Routing Form when health care providers bill certain claim types for Blue Cross Blue Shield of Michigan commercial (non-Medicare) members. The form is used to submit required documentation for a previously submitted claim or to link required documentation to an electronically submitted original claim.

The supporting documentation is necessary to ensure the claim can be reviewed in a timely manner to determine a procedure’s medical appropriateness and service payment amount. When the necessary documentation isn’t attached, claims will be denied.

Blue Cross requires providers to send additional documentation in medical records supporting the treatment provided to the patient for these claim types:

• Individual consideration procedure codes – Send records such as surgical notes or detailed descriptions.
• Not-otherwise-classified procedure codes – Provide additional documentation when the procedure code description data element (Loop 2400 SV202-7) of the electronic claim only provides a partial explanation of the procedure performed.
• Procedure code with modifier 22 – Requires documentation to describe increased procedural services when the work performed is substantially greater than typically required.
• Procedure code with modifier 62 – Requires documentation to describe when two surgeons work together as primary surgeons performing distinct parts of a procedure.
• Procedure code with modifier 66 – Requires documentation in a surgical report to describe the collaboration of more than two surgeons for team surgery.
• Air ambulance – Includes procedure codes A0424, A0430, A0431, A0435 and A0436; requires the ambulance run report and medical records, including the “Medical Transport Justification” documentation, that support the need for air transport versus ground transport.
• Hearing claims with modifier SC – Requires documentation to show medical necessity for the service.
• Cosmetic service claims – Some procedures may be considered either cosmetic or reconstructive based on the indications for surgery; therefore, additional documentation is required to support the statement of medical necessity that justifies the surgery as reconstructive.

The Medical Record Routing form should not be used for secondary claims and timely filing requests. Instead, these should be discussed with Provider Inquiry. Claim denials not related to medical record requests should also be discussed with Provider Inquiry.

If you have any questions or need to speak with Provider Inquiry, call:

• Professional: 1-800-344-8525
• Facility: 1-800-249-5103