Failure to Submit Medical Records

ATTENTION COMMUNITY FIRST PROVIDERS

Texas state regulations (Texas Administrative Code §353.502) require MCOs to conduct routine audits of Provider and Member claims to ensure that proper payments are made.

If you receive a request for medical records, return all documents required of the services billed.

Medical records requests are sent through certified mail, regular mail, and fax.

A documentation checklist will be provided to aid in submitting records to support the billed claims(s) and reimbursement. The checklist will include the following details:

Due date for the submission of records
Where to submit medical records by mail or fax
Patient list which includes:
- Claim number
- Member ID
- Provider name
- Member name
- Member date of birth
- Date(s) of service

We kindly request your prompt response to a medical records request. Failure to respond or submit the necessary documentation for the specified claim and date of service may result in recoupment of the claim.

An appeal will not be accepted for recoupments related to missing medical records or late submissions.

If you have any questions related to auditing or would like to receive an in-service regarding our auditing processes, please contact our Internal Auditor at 210-510-2545.

Community First Resources:

Provider Tip Sheet: Submitting Medical Records