Providers must submit medical records upon initial claim submission of services that are considered experimental, investigational or require medical necessity determination (BlueCard claims do not require this up front submission). Claims submitted without the records may result in the denial 'Medical record submission guidelines not followed' and members will be held harmless. In this case, you may resubmit a new claim with the necessary records.
For contractual reviews, we will continue to contact the provider by letter to request any required clinical information.
Please submit the documentation that best provides supporting evidence for the services rendered.
View the links below for more information: