Collection of Records from Medicare Advantage Plans

4.7.1.3 – Collection of Records from Medicare Advantage Plans (Rev. 13485; Issued: 12-23-25; Effective: 01-26-26; Implementation: 01-26-26) This section applies to the I-MEDIC. As part of the investigative process conducted by the I-MEDIC (regardless of the complaint source), the contractor shall, as appropriate, contact the Medicare Advantage (MA) plan to determine if they have requested and received medical records from the provider. The I-MEDIC shall then request a copy of these records to assist in investigation development. Furthermore, if the MA plan does not possess the requested records, the I-MEDIC may directly request the records from the provider. Before requesting records from a provider, the I-MEDIC shall notify the MA plan. If the I-MEDIC determines that it is inappropriate to request medical records from the plan sponsors, the I-MEDIC shall document its rationale in the Unified Case Management (UCM) system. If the I-MEDIC requests records from a plan sponsor, whose associated entities decline to provide the requested record(s), the I-MEDIC shall promptly notify its BFLs and COR within two (2) business days. 42 CFR §§ 422.504(i)(2)(i) stipulates the requirement for plan sponsors and their associated providers under Part C, to furnish medical records to I-MEDIC upon request. Moreover, the CFRs specify that if Part C plan sponsors are initially informed, the I- MEDIC may request medical records directly from the providers. The only instance in which submitting medical records to the I-MEDIC is voluntary is when the provider is out-of-network. If the plan and its providers fail to submit medical records upon request by the I- MEDIC, CMS’ Center for Medicare (CM) has the authority to take compliance action against the plans for violating their contract with CMS.