Medical Necessity Guidelines for Claims without Medical Records
Customize your policy alerts
Sign up for care_continuum Policy n05677 alerts
Get alerted when Policy n05677 changes without checking for updates manually.
Monitor payer policy activity
Defines how Network Health adjudicates claims when required medical records or documentation are missing and who (claims analysts/utilization management) must follow the process. Applies to NH commercial and Medicare Advantage memberships and staff responsible for claim review.
No material clinical or coverage changes in this revision.
Claims Adjudication and Coverage Rules
Adjudication when documentation is required
Claims requiring additional information will follow this process:
Applies to claims where additional information is required to determine medical necessity.
Staff must refer to the member's Certificate of Coverage, Evidence of Coverage, Summary Plan Description, or Individual and Family Plan to determine eligibility and coverage because employer group/plan sponsor and government contracts may vary. For Medicare Advantage members, Network Health follows Medicare National/Local Coverage Determinations for adjudication and applicable coverage rules.
A request for payment of a claim for which additional information is needed to determine medical necessity will be denied as not reasonable and medically necessary if the supporting information or medical records are not received by the specified due date established in accordance with this policy.
Provider Documentation, Requests, and Denial Actions
Documentation & coding requirements
Appropriate coding and billing procedures must be followed and submitted on the claim; for Medicare Advantage membership, services must meet Medicare coverage, coding, and medical necessity requirements.
Provider must submit requested records when asked
When medical records or other supporting documentation are required to determine medical necessity, the provider must submit the requested records promptly as specified in outreach from NH staff to avoid denial.
- Providers are responsible for supplying medical records listed in policy (e.g., history & physical, discharge summary, lab reports, physician consults, medication administration record, progress notes, therapy flowsheets).
Examples of required supporting documentation
Information that may be required to prove medical necessity includes medical records (history and physical, discharge summary, lab reports, physician consults, medication administration record, progress reports, therapy flowsheets), certificate of medical necessity, proof of delivery documentation, and receipt of payment.
- History and Physical
- Discharge Summary
- Lab reports
- Physician consults
- Medication administration record
- Progress reports
- Therapy (PT/OT/ST) flowsheets
- Certificate of medical necessity
- Proof of delivery documentation
- Receipt of payment
NH outreach will state required docs and due date
NH staff will make outreach specifying exactly what documentation is needed and will include the date by which the information is required; providers must respond by that due date.
- Outreach will specify the exact type of documentation requested.
- Outreach will include the date by which the information is required.
Claims denied if records not received by due date
If the requested records or supporting information are not received by the specified due date, the claim will be adjudicated to deny as not reasonable and medically necessary and the denial code will indicate services were deemed not medically necessary.
- Failure to provide records by the due date results in claim denial.
- Denial code will indicate services were deemed not medically necessary.
Policy Purpose and Scope
This is an administrative policy to guide consistent adjudication when required medical records or other supporting documentation are missing. When documentation is requested, NH staff will specify exactly what is needed and provide a due date; if the requested records are not received by that due date the claim will be denied as not reasonable and medically necessary. The policy applies to Network Health commercial and Medicare Advantage memberships and aligns Medicare Advantage adjudication with Medicare national/local coverage determinations.
Examples of supporting documentation that may be requested include medical records such as history and physical, discharge summary, lab reports, physician consults, medication administration record, progress reports, therapy flowsheets, certificate of medical necessity, proof of delivery, and receipt of payment. Appropriate coding and billing procedures must be followed and submitted on the claim.
Supporting Documentation Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.