Timely Receipt of Records

Policy No: 145
Originally Created: 10/01/2022
Section: Administrative
Last Reviewed: 09/11/2025
Last Revised: 09/11/2025
Approved: 09/11/2025
Effective: 01/01/2026
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.

Note: This policy is not effective until 1/1/2026. To view the current policy, click here.

Record Requests
This policy applies when the health plan reviews a claim, and requires additional documentation to adjudicate the claim. Provider must return to the health plan the records requested by the health plan in order for the claim to be adjudicated. The following is the process for requesting records and subsequently adjudicating the related claim:

• 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, if there is no date specifified in the request or in the contract, within 10 calendar days from the date of the request.
• 45-day notification: If the health plan does not receive requested records and/or related documentation 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 health plan does not receive the requested records within 90 calendar days from the date of the initial request, the health care 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.

Incomplete requests and records received after the 90-day period will not be accepted and will not change the adjudication of the claim. To have records reviewed beyond the 90-day deadline, the formal appeal process must be followed.

Medicare Claims Processing Manual, Chapter 1 - General Billing Requirements

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