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Medical - Submission of Clinical Records / General Requirement

Aetna routinely requires submission of clinical records before payment of claims when the claim includes:

• a code appended with Modifier 22 (unusual procedural service), for example, an operative report for surgical procedures, office notes for non-surgical procedures, or
• an “unlisted code” as defined in the Index of CPT as “unlisted services and procedures”, or
• a code from the list of other “nonspecific” codes  (1 page)

Beyond these categories, we may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is reasonable basis for believing such investigation is warranted.

This policy is not designed to limit Aetna’s right to require submission of medical records for precertification purposes.