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Medical Record Submission Requirements
Medical Record Submission Requirements

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.

View the links below for more information:

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 retrievel 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 retrievel 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.

Risk Adjustment Activities
By Line of Business
Medical Record
Collection
Starting Timeframe
Record Retrieval Vendor
(independent company from our Health Plan)
Dates of Service
Commercial
HHS RADV Audit
August 2018 Change Healthcare Calendar Year 2017
Medicare
Advantage Retrospective
Risk Adjustment Audit
August 2018 CIOX Health, LLC
(fka ArroHealth)
Calendar Year 2017
through present date
ACA Commercial
Retrospective Risk Adjustment Audit
February 2019 CIOX Health, LLC
(fka ArroHealth)
Calendar Year 2018
Medicaid
Retrospective Risk Adjustment Audit
April 2019 Change Healthcare Calendar Year 2018
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