As a reminder, when you receive a claim audit with a request for medical records, it’s important to comply within the allowed timeframe. In alignment with industry standards, Priority Health will apply technical denials to audited claims when they don’t receive the requested medical records. They’ll begin applying these denials to in-network providers’ claims on December 29, 2024.

Technical denials: definition, timeline, outcome

A technical denial is an administrative claim denial issued when a provider doesn’t respond to requests for medical records.

When a paid claim is identified through audit as requiring medical record review, providers receive three requests to submit medical records. These letters include a list of the requested medical records and instructions for submission and state the claim will be denied if they don’t submit the requested records within 45 days of notice.

If the medical records aren’t submitted by the deadline, Priority Health will deny the paid claim to provider liability and take back the paid funds. The claim may show a denial code which indicates additional documents are required.

Extension for current, outstanding medical record requests

As we approach the end of the year, Priority Health would like to offer an extension on all current, outstanding medical record requests on audited claims. Please submit medical records by December 29, 2024.

After a technical denial

Even after a technical denial is issued, you can submit the requested medical records to the requestor for consideration.

For funds recoupment click here and follow the corrections to overpayments process, or they’ll recoup from future claims payments.