We routinely ask medical professionals to submit clinical records before we pay a claim if the claim includes:
• A code appended with Modifier 22 (unusual procedural service), for example, an operative report for surgical procedures or office notes for non-surgical procedures
• An “unlisted code” as defined in the Index of CPT as “unlisted services and procedures”
• A code from the list of other “nonspecific” codes (PDF, 29 KB)
We may ask you to submit clinical records before or after payment of claims to investigate potentially fraudulent, abusive or other inappropriate billing practices. We will only make this request if there is a reasonable basis for believing such an investigation is warranted.
This policy is not designed to limit Aetna’s right to request that medical professionals submit clinical records for precertification.