Policy No: 119
Originally created: 11/01/2013
Last Reviewed: 10/01/2019
Last Revised: 04/01/2019
This policy applies to all providers and facilities.
Services that are related to or in support of services denied as non-covered, including investigational, cosmetic, not medically necessary 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, 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 any assistant surgeon
- By any anesthesia 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
By the provider without the required pre-authorization