Submitting Medical Records

If prior authorization has not been obtained, providers must submit medical records upon initial claim submission of services that are considered experimental, investigational or require medical necessity determination. Claims submitted without the records may result in the denial 'Medical record submission guidelines not followed' and members will be held harmless. In this case, you may resubmit a new claim with the necessary records.

For contractual reviews, we will continue to contact the provider by letter to request any required clinical information.

Please submit the documentation that best provides supporting evidence for the services rendered.

Practitioners are expected to provide services that are supported by accurate medical documentation. Accurate documentation is recognized as specific to an individual patient’s medical evaluation, treatment, and/or change in clinical condition.

All practitioners documenting in the medical record must avoid copying and pasting indiscriminately (i.e., cloning) progress notes and duplicate/redundant information provided in other parts of the medical records. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services because of the absence of specific individual data for the individual patient. Identification of cloning may lead to denial of services and recoupment of all overpayments made.

View the links below for more information:

• Procedure Codes that Require Medical Record Submission Open a PDF
• Basic Medical Record Documentation Standards Open a PDF
• Partnering On Risk AdjustmentOpen a PDF
• Risk Adjustment FAQsOpen a PDF
• Procedure Codes that Require Dental Record SubmissionOpen a PDF

Retrospective Risk Adjustment Medical Record Requests

Medical records requests are a key part of our Health Plan's Risk Adjustment activities. Your office may receive medical records requests to support the programs listed in the chart below; and sending the records and/or allowing us to retrieve them from your office, is a condition of your participating provider agreement with our Health Plan.

In some instances, our Health Plan has data validation audits that involve the retrieval of medical records taking place concurrently. We do our best to avoid duplicative record requests; however, if you receive multiple requests for medical records, please follow the instructions provided in each request.

Our Health Plan has executed a Business Associate Agreement with our record retrieval vendors, which are independent companies, and we have implemented appropriate safeguards to ensure full compliance with all defined privacy and security provisions.

Thank you for your prompt attention to these requests and your participation.