The following is a list of claims categories where National Capital PPO (NCPPO) may routinely require submission of Clinical Information prior to pricing or processing a claim. This does not limit what a health plan claims administrator or health carrier may require to determine benefits.

1. Claims involving pre-certification/prior authorization or some other form of utilization review including but not limited to:
• Claims pending for lack of precertification or prior authorization;
• Claims involving Medical Necessity or Investigative; determinations through the application of clinical guidelines and/or medical policies; and
• Claims for pharmaceuticals requiring prior authorization.

Please refer to the NCPPO Provider Manual on the “Physician and Hospital” pages of the NCPPO website, located at www.ncppo.com for a current listing of services requiring precertification or prior authorization for health plans that use the NCPPO Utilization Management Program in conjunction with access to the NCPPO network(s) of participating health care providers. Refer to the Utilization Management organization identified on the Enrollee ID card if another organization is performing Utilization Management on behalf of the enrollee's health plan. In addition, the current WellPoint Medical Policies are available on the NCPPO website as a reference guide to criteria used by NCPPO related to medical necessity and investigational care.

2. Claims involving certain modifiers.
3. Claims involving unlisted procedural codes, including category III codes and unlisted HCPCS codes as well as unlisted CPT codes.
4. Claims for which the claims administrator (including NCPPO HMO), Plan Administrator, or health carrier cannot determine from the face of the claim whether it involves a Covered Service thus the benefit determination cannot be made without reviewing medical records (including but not limited to pre-existing condition issues, emergency service-prudent layperson reviews, specific benefit exclusions, benefit maximums).
5. Claims that NCPPO, the Plan Administrator, or health carrier has reason to believe involve inappropriate billing
6. Claims that are the subject of an audit (internal or external) including high dollar claims.
7. Claims for individuals involved in case management or disease management.
8. Claims that have been appealed (or that are otherwise the subject of a dispute, including claims being mediated, arbitrated, or litigated)
9. Other situations in which clinical information might be requested:
• Requests relating to underwriting (including but not limited to 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.

To facilitate timely claim processing and benefit consideration, please submit supporting clinical information directly to the party who requests the information. For example, if a Plan Administrator's office requests clinical information, respond directly to the Plan Administrator rather than to NCPPO. If NCPPO requests clinical information to price the claim appropriately, this clinical information is forwarded to the Plan Administrator or health carrier along with the claim to support efficient claim adjudication and benefit consideration by the payor.