Prepayment review denials for lack of medical records
For prepayment reviews, medical records and/or related documentation are required. When IntegraNet Health needs additional documentation to adjudicate
the claim, the claim will be pended until the documentation is received or until the deadline for receipt of the documentation passes.
Medical record request for Prepayment Reviews
Initial request: For prepayment reviews, medical records and/or related documentation are required. When IntegraNet Health needs additional
documentation to adjudicate the claim, the provider will receive a notice requesting medical records and the claim will be pended until the documentation
is received or until the deadline for receipt of the documentation passes.
Additional outreach attempts: If medical records and/or related documentation are not received within the first (15 days) of the date the notice is sent,
a second request will be mailed to the provider requesting that the records and/or documentation be provided within (15 days) of the date of the second notice sent.
Explanation of remittance (EOP) notification: If the requested medical records are not received within (30 days) the required time frame,
the healthcare provider will receive an EOP showing the full denial of the claim due to lack of documentation to substantiate the services billed.
Failure to submit medical records within the (15-day) time frame of the EOP notification, the initial determination to deny for medical record not submitted timely,
a technical denial will be issued and is not subject to appeal (“technical denial”).