Associated Claims
Services that are related to or in support of services denied as non-covered including: investigational, cosmetic, not medically necessary services, non-covered items and services, and contract exclusions. An example of an associated claim is the bill from an assistant surgeon for a cosmetic surgery. The bill from the surgeon is considered the primary claim. The bill from the assistant surgeon is the associated claim.
Our health plan will deny reimbursement for claims associated with denied services including: investigational, cosmetic, not medically necessary services, non-covered items and services, and contract exclusions. This applies to all services and claim types. In addition, we will not allow providers or members to retain reimbursement from us for these associated claims. Responsibility for the costs associated with these claims will be assigned to the provider or member depending on the denial type.
Some examples of services that may be denied as associated claims include, but are not limited to, services provided or performed:
- By the provider or associate performing the denied service
- By the provider without the required pre-authorization
- By any provider billing evaluation and management (E&M) related services
- By any assistant surgeon
- By any anesthesia provider
- By any pathology provider
- By any radiology provider
- By the facility where the service was performed
- At the same time or during the same operative session (regardless of whether the service was billed)
Prior to or subsequent to an initial related denied service
In the case of equipment that is not covered, related services would include, but are not limited to:
- Supplies
- Batteries
- Replacement equipment
Set-up fees
None
None
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.