Timely Receipt of Records

Policy No: 145
Originally Created: 10/01/2022
Section: Administrative
Last Reviewed: 12/1/2023
Last Revised:
Approved: 12/14/2023
Effective: 01/01/2024
Policy Applies To: Group and Individual & Medicare Advantage

This policy applies to all physicians, other health care professionals, hospitals, and other facilities.

Claim Adjudication – Process of the health plan determining if the claim should be reimbursed in full, denied, or reimbursed at a reduced rate.

Clean Claim – A claim that does not need additional information in order to determine reimbursement

Unclean Claim – A claim missing key information needed to determine reimbursement, for which additional records may be requested.

Record Requests

This Policy applies when a claim is reviewed, and additional documentation is needed to adjudicate the claim. Provider must return the requested records to the health plan in order for the claim to be adjudicated. The following is the records request and claim adjudication process:

• Initial request: Notification to the healthcare provider will occur via mail, email, fax or Availity® with a description of the records and/or additional documentation needed and a request to provide this information. All documentation requested must be provided within the time frame specified in the request, as stated in provider contract or within 10 calendar days from the date of the request if no date is specified in the request or contract.
• 45-day notification: If records and/or related documentation are not received within 45-calendar days of the notification, the health plan will reach out to our Commercial member(s) letting them know records have not been received.

• Denial notification: If the requested records are not received within 90 calendar days from the date of the initial notification, the healthcare provider will receive a denial via remit process stating provider liability, due to lack of documentation to substantiate the services billed.

For expedited handling, providers should respond to a records request using the same format in which the request was received or as indicated in the records request. Providers should reply to records requests through Availity when received via the Availity Attachments application.

If at any time during the above process the records are received, the claim will be reviewed and a determination will be made to reimburse the claim in full, deny the claim, or reimburse the claim at a reduced rate.

Medicare Claims Processing Manual, Chapter 1 - General Billing Requirements

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