The Importance of Medical Records

As many of you know, insurance companies handle nutritional counseling benefits differently. In many cases, you can submit a claim for a patient without any medical diagnoses and get paid! In some cases, insurance companies require that the patient is diagnosed with a medical condition to qualify for nutritional counseling benefits. And in a few cases, insurance companies will request that you send medical records along with the claim (or after the claim is submitted) to determine whether the patient’s diagnosis is covered for nutritional counseling under their policy.

What do insurance companies mean by “medical records”?

Medical records can come in many forms! Typically, insurance companies are looking for the clinical notes from your visit with the patient, which explains the reasons the patient is seeing you and what you are doing to treat them. If possible, you can also send medical records you’ve obtained from the patient’s Primary Care Physician that relate to the reason you are seeing the patient. When it comes to medical claim review, the more information the better!

How do I know if medical records are required?

We always recommend asking if medical records are required for filing claims when calling to the check patient benefits. But sometimes, even if you were told they won’t be needed, insurance companies hold the right to request more information (ugh). In these cases, you’ll generally receive a letter in the mail shortly after the claim is filed, which requests medical records and explains where to send them.

What happens when the insurance company receives the medical records?

Once the insurance company receives the medical records, they will review the information you’ve sent to determine whether the visit is medically necessary under the patient’s policy. In other words, whether the patient’s plan will cover it.

What if the claim is denied after the insurance company reviews the medical records?

Once a claim is denied based on medical necessity, it can only be appealed by the patient. This is because you’ve told the insurance company everything you can about your side of things, now it’s between the patient and their insurance policy. With some insurance companies, it’s possible for the patient to sign a consent form, which allows you to file the appeal on their behalf. Either way, this is one of the many reasons we stress the importance of setting expectations early on with your clients about their Patient Policies!