Duplicative or Excessive Medical Records Requests

----\ Michael Preston SECRETARY OF COMMERCE AID •DX AAAAA IMSUPAY. * * December 1, 2022 BULLETIN NO. 14-2022 TO: FROM: SUBJECT: All Health Insurers and Health Maintenance Organizations ARKANSAS INSURANCE DEPARTMENT Duplicative or Excessive Medical Records Requests Alan McClain COMMISSIONER, ARKANSAS INSURANCE DEPARTMENT The Arkansas Insurance Commissioner ("Commissioner") issues this Bulletin in response to a complaint from a hospital and concerns raised about the same issue from medical provider organizations. The purpose of this Bulletin is to remind health insurers and health maintenance organizations ("HMOs") to avoid requesting duplicative and unnecessary medical records to adjudicate claims or to process prior authorizations. The Commissioner reminds the health insurance industry of Rule 43, Section 13. If a claim is not "clean," or needs additional medical information for processing, there must be a "reasonable basis" for requesting such additional information under Rule 43, Section 13(b). The Commissioner views that the requesting of additional medical records by the health carrier after such records have already been provided to the carrier to be a violation of this subsection. Once the carrier has sufficient medical records to make a claim or prior authorization decision, the carrier must either pay or deny the claim within thirty (30) days under Rule 43, Section 13(c). The making or creating of additional, repetitive medical records requests, after previously receiving such records may be interpreted by the Commissioner to be dilatory toward the payment of a claim or prior authorization. Once all of the necessary information is received by a carrier, the requesting of additional records does not suspend the payment or adjudication of the claim under Rule 43, Section 13 (c) and may result in a payment of interest penalties under Rule 43, Section 13 (d). The Commissioner reminds health insurers and HMOs that such dilatory and unnecessary requests may additionally result in trade practice penalties. Therefore, the Commissioner hereby provides the health insurance industry notice that the Arkansas Insurance Department ("Department") will more energetically review medical provider complaints to determine whether there exists dilatory, repetitive, or frivolous medical records requests in the adjudication of claims and prior authorizations. In addition, the Commissioner advises health insurers and HMOs subject to the Department's examination provisions that the Department may audit samples of claims for compliance with the principles of this Bulletin. For questions pertaining to this Bulletin, please contact Booth Rand, General Counsel, at the Arkansas Insurance Department at 501-371-2820. ALAN MCCLAIN ARKANSAS INSURANCE COMMISSIONER Arkansas Department of Commerce Arkansas Insurance Department 1 Commerce Way, Suite 102 • Little Rock, AR 72202 INSURANCE.ARKANSAS.GOV a -- DATE