How to Use Medical Records to Fight Denial of Claims

Get Your
Medical Records

1

Complete a simple secure form

2

We contact healthcare providers on your behalf

3

Have a National Medical Records Center send your records as directed

i 3 Table of Contents

Denied health insurance claims are a common frustration for patients and providers alike. A claim denial can disrupt access to care, delay treatments, and create financial burdens. However, medical records—when accurate, complete, and strategically used—are the most powerful tools for reversing these decisions.

This guide offers an in-depth look at how to effectively leverage medical records to fight claim denials, helping patients secure the coverage and care they need.

Understanding Claim Denials

What Are Claim Denials?

A denied claim occurs when an insurance company refuses to pay for a medical service or procedure. Denials can stem from several reasons:

  • Errors in Submission: Typos, incorrect codes, or missing details
  • Lack of Documentation: Insufficient evidence of medical necessity
  • Policy Limitations: Treatments not covered under the patient’s plan
  • Preauthorization Issues: Procedures performed without prior approval

How Medical Records Help

Medical records address the core reasons behind claim denials by:

  • Providing evidence of medical necessity
  • Demonstrating compliance with industry standards like ICD-10 and CPT codes
  • Supporting appeals with detailed patient histories, test results, and treatment plans

Who Benefits from This Guide?

  • Patients navigating the appeals process for denied claims
  • Healthcare Providers tasked with creating accurate documentation
  • Claims Specialists responsible for reducing denial rates and maximizing reimbursements

The Role of Medical Records in Fighting Denials

1. Accuracy and Detail

Precise and thorough medical records ensure that all aspects of a patient’s care are documented. This includes:

  • Diagnosis and treatment plans
  • Test results and imaging reports
  • Notes on progress and follow-up care

Tip: Use standardized templates to maintain consistency across documentation.

2. Timely Updates

Real-time updates to medical records prevent delays in addressing denials. For example, a claim for ongoing physical therapy may require the latest progress notes to substantiate the continued need for treatment.

3. Compliance with Standards

Claims must meet insurer and regulatory standards. Medical records should include:

  • ICD-10 codes for diagnoses
  • CPT codes for procedures and services rendered
  • Documentation of preauthorization, when required

Step-by-Step Guide to Fighting Denied Claims with Medical Records

Step 1: Understand the Denial

Carefully review the Explanation of Benefits (EOB) or denial letter to determine the reason for denial. Insurers typically include codes and brief descriptions indicating why the claim was denied.

Step 2: Gather Supporting Documentation

Compile all relevant medical records, including:

  • Physician’s notes and treatment plans
  • Diagnostic test results
  • Copies of prior authorizations
  • Letters of medical necessity, if applicable

Step 3: Verify Compliance

Ensure that the documentation aligns with the insurer’s requirements:

  • Check coding accuracy (ICD-10, CPT)
  • Confirm that the documentation includes sufficient detail to justify the claim

Step 4: Write a Strong Appeal

Draft an appeal letter addressing the denial. Include:

  • A clear explanation of why the claim should be approved
  • Supporting evidence from the medical records
  • References to any applicable policy terms or legal requirements

Tip: Structure the letter concisely, using bullet points to highlight key arguments.

Step 5: Follow Up

Submit the appeal and track its progress. Insurers may require additional information or clarification, so be prepared to respond promptly.

Common Challenges and Solutions

Challenge Solution
Missing or Incomplete Records Use checklists to verify documentation before submitting claims
Coding Errors Train staff on ICD-10 and CPT coding or use AI-powered auditing tools
Non-Standard Documentation Implement templates to ensure consistency and compliance

Leveraging Technology to Strengthen Medical Records

1. Electronic Medical Records (EMRs)

EMRs simplify record-keeping, enabling healthcare providers to:

  • Automate coding and error checks
  • Integrate medical records with billing systems
  • Provide secure, cloud-based access to data

2. Artificial Intelligence (AI)

AI tools can proactively flag potential issues in documentation, such as:

  • Missing test results
  • Discrepancies in treatment plans and diagnoses
  • Incomplete records required for specific claims

3. Data Analytics

Analytics platforms identify patterns in claim denials, helping organizations address recurring issues and refine documentation practices.

Benefits of Proactive Record Management

1. Higher Approval Rates

Comprehensive and accurate records reduce the likelihood of denial and strengthen appeal cases.

2. Faster Resolution

Well-organized documentation ensures that appeals are processed quickly, minimizing delays in care and reimbursement.

3. Cost Savings

Preventing claim denials reduces administrative expenses associated with re-submissions and appeals.

Frequently Asked Questions

What medical records are essential for appeals?

The key records include:

  • Treatment plans and progress notes
  • Diagnostic test results
  • Preauthorization and referral documents

Can patients access their own medical records for appeals?

Yes, under HIPAA regulations, patients have the right to request copies of their medical records. Providers must supply the records within 30 days of the request.

How long does it take to resolve a denied claim?

Resolution times vary, but well-documented appeals are typically resolved within 30–90 days.

Support Resources

  • EMR Providers: Tools like Epic and Cerner support documentation and claims management
  • NAIC: The National Association of Insurance Commissioners offers consumer assistance for complex claim issues
  • Legal Support: For disputes requiring legal action, consult firms specializing in insurance law

Final Thoughts

Denied claims can be a significant hurdle for patients and providers, but leveraging medical records effectively can make all the difference. From understanding denial reasons to crafting evidence-based appeals, accurate and complete documentation is the cornerstone of successful claim resolution.

By adopting proactive practices, using advanced technologies, and following the steps outlined in this guide, you can significantly improve claim approval rates and streamline the appeals process.

If you’re navigating a denied claim, start by organizing your medical records and seeking professional assistance when needed.