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Pre-payment Review

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Many insurance plans do not require pre-certification however, before a claim is processed they may request patient records to justify that the services billed match the services provided. This is a common practice with United Healthcare in which they scrutinize the provider's notes. If the CPT-4 codes on the HCFA-1500 claim form are not medically justified by the notes then it will result in a partial or full denial of the claim. ASMPC will notify the provider if such a situation exists and will conduct their own audit prior to submission. If found to be inadequate, ASMPC will advise provider of the proper documentation needed.

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