Reminder: Our technical denials policy, submit outstanding medical record requests

As a reminder, when you receive a claim audit with a request for medical records, it’s important to comply within the allowed timeframe. In alignment with industry standards, we apply technical denials to audited claims when we don’t receive the requested medical records. We’ll begin applying these denials to in-network providers’ claims on Dec. 29, 2024.

Technical denials: definition, timeline, outcome

A technical denial is an administrative claim denial issued when a provider doesn’t respond to requests for medical records.

When a paid claim is identified through audit as requiring medical record review, providers receive three requests to submit medical records. These letters include a list of the requested medical records and instructions for submission and state the claim will be denied if they don’t submit the requested records within 45 days of notice.

If the medical records aren’t submitted by the deadline, we deny the paid claim to provider liability and take back the paid funds. The claim may show a denial code which indicates additional documents are required.

Extension for current, outstanding medical record requests

As we approach the end of the year, we’d like to offer an extension on all current, outstanding medical record requests on audited claims. Please submit medical records by Dec. 29, 2024.

After a technical denial

Even after a technical denial is issued, you can submit the requested medical records to the requestor for consideration.

For funds recoupment, follow our corrections to overpayments process, or we’ll recoup from future claims payments.