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43 11/2005
• Claims involving unlisted codes
• Claims for which we cannot determine from the face of the claim whether it
involves a Covered Service thus the benefit determination can’t be made
without reviewing medical records (including but not limited to pre-existing
condition issues, emergency service-prudent layperson reviews, specific benefit
exclusions).
• Claims that we have reason to believe involve inappropriate (including
fraudulent) billing
• Claims that are the subject of an audit (internal or external) including high
dollar claims.
• Claims for individuals involved in case management or disease management.
• Claims that have been appealed (or that are otherwise the subject of a dispute,
including claims being mediated, arbitrated, or litigated)
• Other situations in which clinical information might routinely be requested:
• Requests relating to underwriting (including but not limited to member or
physician misrepresentation/fraud reviews and stop loss coverage issues);
• Accreditation activities;
• Quality improvement/assurance activities;
• Credentialing;
• Coordination of benefits; and
• Recovery/subrogation.
Examples provided in each category are for illustrative purposes only and are not
meant to represent an exhaustive list within the category.